Question 1

CLUSTER HEADACHES

Accepted Answer

What are cluster headaches?

Cluster headaches are a primary headache disorder, meaning they’re a condition of the nervous system rather than a headache caused by something else like an infection or bleeding. They come in attacks: sudden bursts of severe, one-sided head pain that usually center around the eye, temple, or forehead.¹

A defining feature is that the pain happens with “same-side” facial and eye symptoms, like tearing or a stuffy nose, and many people feel restless or agitated during attacks.¹ This combination, pain plus autonomic (automatic nervous system) symptoms, is part of how clinicians recognize cluster headache as distinct from migraine and other headache types.¹

What does a cluster headache attack feel like, and what symptoms come with it?

Cluster headache pain is typically described as severe or very severe, and it’s usually focused on one side of the head, often around or behind one eye.¹ The pain can feel stabbing, burning, or drilling, and it often ramps up quickly rather than building slowly.¹

During the pain, the body may show “autonomic” symptoms on the same side as the headache. These can include a red or watery eye, a runny or blocked nostril, facial sweating, eyelid swelling, a drooping eyelid, or a smaller pupil.¹ Many people also feel a strong sense of restlessness, like they can’t lie still.¹

How long do cluster headache attacks last, and how often can they happen?

A typical cluster headache attack lasts 15 to 180 minutes when untreated.¹ That time window matters because it helps clinicians separate cluster headache from other disorders that can look similar.¹

Attacks can occur from once every other day up to eight times per day.¹ They often happen in patterns, for example at similar times of day, including waking someone from sleep.¹ This clock-like pattern is one reason cluster headache is sometimes described as having a strong “biological rhythm.”⁹

What is the difference between episodic and chronic cluster headaches?

Episodic cluster headache means attacks happen in “cluster periods” (also called bouts) that last from 7 days to 1 year, separated by pain-free remission periods that last at least 3 months.² People may go months or even years without attacks, then experience another bout.²

Chronic cluster headache means attacks have been occurring for at least 1 year without remission, or with remissions lasting less than 3 months.³ This distinction matters because treatment planning can differ, especially around long-term prevention and advanced therapies.⁴⁵

What causes cluster headaches in the brain and nervous system?

Cluster headache is strongly linked to changes in brain circuits that help regulate pain, the autonomic nervous system, and body rhythms like sleep-wake timing. Imaging studies during attacks have shown activation in the hypothalamus region, which is involved in timing and autonomic control.⁹

Another key concept is the trigeminal-autonomic reflex. In plain language: pain pathways carried by the trigeminal nerve can “couple” with facial autonomic pathways, which helps explain why severe one-sided pain can occur alongside tearing, nasal congestion, and other same-side symptoms.¹⁰¹¹ This is also why some treatments target nerves or ganglia (nerve hubs) connected to these circuits.⁴¹⁰

Who tends to get cluster headaches, and what are known risk factors?

Cluster headache is uncommon, affecting roughly about 0.1% of people in many population estimates.¹¹ It is more common in men than women, although the gap varies across studies and may be narrowing in some datasets.¹¹

Some factors are associated with cluster headache, but association is not the same as cause. For example, higher rates of current or past tobacco use have been reported in many cluster headache populations, and alcohol is a commonly reported trigger during active bouts.¹¹¹² If you’re looking for “the one cause,” it’s more accurate to think of cluster headache as a nervous system condition with multiple influences, some of which still aren’t fully understood.¹¹

What triggers cluster headache attacks, and why do triggers matter most during a cluster period?

Many people notice that certain exposures trigger attacks during a cluster period, especially alcohol.¹² Others report triggers like strong smells, heat, or changes in sleep patterns, but triggers vary widely from person to person.¹²

A useful way to think about it is this: during a cluster period, the nervous system is in a more “ready to fire” state, and small inputs may set off an attack.⁹¹¹ Outside a cluster period, those same exposures may not trigger anything. Tracking this pattern can help you and your clinician decide what’s worth avoiding and what’s just background noise.¹²

How are cluster headaches diagnosed?

Cluster headache is diagnosed clinically, meaning the diagnosis is based on your story and symptom pattern more than on a single lab test. Clinicians look for the defining features: severe, one-sided attacks lasting 15 to 180 minutes, occurring up to eight times per day, with same-side autonomic symptoms and often restlessness.¹

A typical evaluation includes a careful headache history, a neurologic exam, and questions about timing, frequency, and what happens to the eye and nose on the painful side.¹² When the pattern matches the International Classification of Headache Disorders (ICHD-3) criteria, that strongly supports the diagnosis.¹

When do clinicians consider imaging like MRI for cluster headaches?
Imaging is usually considered when clinicians want to rule out secondary causes that can mimic cluster headache or other trigeminal autonomic cephalalgias (TACs).¹²³ Conditions that can sometimes imitate TAC-like symptoms include certain pituitary region problems, vascular issues, or other structural causes, even though these are not the typical explanation for classic cluster headache.¹³

Many clinicians are more likely to recommend MRI when the presentation is atypical, new in onset, changes significantly, does not respond as expected to standard therapy, or comes with abnormal neurologic findings on exam.¹²¹³ The goal is reassurance and safety: confirming you’re treating the right condition with the right plan.¹³

What are the first-line treatments that can stop an attack quickly?

Guidelines consistently place two options at the top for acute attacks: high-flow 100% oxygen and subcutaneous sumatriptan.⁴⁵ These are recommended because they can work quickly, which matters when attacks peak fast.¹⁴⁵

Nasal triptans, especially zolmitriptan or sumatriptan nasal spray, are also used, but they tend to have a slower onset than an injection.⁴⁵ The best acute plan is often the one you can start within minutes, so practical access, training, and speed matter as much as the medication choice.⁴¹²

How does high-flow oxygen work, and what should I ask about equipment and flow?

High-flow oxygen (100%) is recommended at a flow of at least 12 L/min for about 15 minutes for an acute cluster attack.⁴ This approach has randomized trial support and is widely recommended in professional guidance.⁴⁶

Oxygen success can depend on the delivery setup, not just the prescription. It’s reasonable to ask your clinician or oxygen supplier about:
 • Flow rate options (at least 12 L/min, and sometimes higher if prescribed)⁴
 • Mask type, since a non-rebreather mask is commonly used for cluster headache delivery⁴
 • Whether your system can deliver the needed flow consistently for the full treatment window⁴
 • A plan for portability or access outside the home if attacks occur away from your main setup⁴

How do triptan medicines fit in, and what safety limits and heart-related cautions come up?

Subcutaneous sumatriptan 6 mg is a first-line acute option and is valued for speed.⁴⁵ The FDA label describes 6 mg as the maximum single adult dose for injection, with a maximum cumulative dose of 12 mg in 24 hours.⁷

Triptans can be unsafe for some people with specific cardiovascular conditions, and the FDA label lists key contraindications such as ischemic coronary artery disease and coronary vasospasm, among others.⁷ If you have heart disease, risk factors, or unexplained chest symptoms, it’s important to discuss this with your clinician before using triptans, so the acute plan matches your overall risk profile.⁷

What is preventive treatment, and when does it start?

Preventive treatment aims to reduce how often attacks happen during a cluster period and, for chronic cluster headache, to reduce ongoing attack frequency over time.⁴ The timing matters: prevention is often started early in a bout because it may take days to weeks to fully take effect.⁴

For many people, prevention is paired with a short-term “bridge” (transitional) treatment so they’re not left suffering while the preventive medication is ramping up.⁴ This is a common, practical strategy in guideline-based care.⁴⁵

Why is verapamil often first-choice, and what monitoring is usually needed?

Verapamil is commonly used as a first-choice preventive medication for cluster headache, and guidance often starts at a total daily dose of at least 240 mg, then adjusts based on response and tolerability.⁴⁵ In practice, the dose is titrated, meaning increased step-by-step, aiming for the lowest dose that controls attacks.⁴

Because verapamil can affect heart rhythm and conduction, ECG monitoring is emphasized, especially as doses increase.⁴ Studies in cluster headache populations have reported ECG abnormalities and conduction issues in some people treated with higher-dose verapamil, which is why monitoring is treated as part of the therapy, not an optional extra.⁴¹⁵¹⁶ If verapamil is on the table, it’s reasonable to ask what ECG schedule your clinic uses during dose changes and at stable doses.⁴¹²

What are transitional or bridge treatments, and why are steroids or nerve blocks used?

Bridge treatments are short-term approaches meant to reduce attacks quickly while longer-term preventives, like verapamil, are being started or adjusted.⁴ This can be especially important in the early days of a cluster period when attacks are frequent and severe.⁴

Corticosteroids are one bridge option, used for short periods with a tapering plan.⁴ Another bridge approach is a greater occipital nerve area steroid injection (often called a suboccipital steroid injection or occipital nerve block), which has randomized trial evidence showing reduced attack frequency for some patients.⁴¹⁷¹⁸ These strategies should be planned carefully with a clinician because repeated or prolonged steroid exposure carries risks, and the goal is short-term control, not long-term dependence.⁴

What other preventive options might be discussed if verapamil isn't a good fit?

If verapamil is ineffective, not tolerated, or not safe for someone’s medical situation, clinicians may discuss alternatives such as lithium or topiramate.⁴ Lithium is often described as a second-choice option in major guidance when verapamil can’t be used, and it typically involves blood level monitoring.⁴

Topiramate has been used as a preventive option with supportive, though more limited, evidence compared with first-line choices.⁴ In real-world care, the “right” preventive is often the one that balances benefit with side effects, monitoring burden, and your specific health history.⁴⁵

What is galcanezumab (a CGRP antibody), and how does country approval differ?

Galcanezumab is a monoclonal antibody that targets CGRP (calcitonin gene-related peptide), a molecule involved in pain signaling.⁸ In the United States, the FDA label includes an indication for episodic cluster headache in adults, with a recommended dose of 300 mg monthly during the cluster period (given as three 100 mg injections).⁸

Approval differs internationally. The European Medicines Agency (EMA) lists Emgality for migraine prevention, and an EMA public assessment report documents a negative opinion for the cluster headache extension request.¹⁹²⁰ In Canada, public materials describe an episodic cluster headache indication.²¹ If you live outside the US, it’s worth asking your clinician what is approved, what is available, and what insurance or public systems will actually cover where you are.¹⁹²¹

What is non-invasive vagus nerve stimulation, and who might it help?

Non-invasive vagus nerve stimulation (nVNS) is a device-based therapy applied externally, usually at the neck, intended to influence nerve pathways involved in headache.⁴ It is discussed in guidelines as an option for some patients, and recommendations may differ depending on whether the cluster headache is episodic or chronic.⁴

In the 2023 EAN guideline summary, nVNS is recommended for acute attacks in episodic cluster headache but not chronic cluster headache.⁴ If you’re considering nVNS, ask about realistic expectations, how to use it during an attack, and what criteria your clinician uses to decide whether it’s worth a trial in your specific subtype.⁴

What does “refractory” chronic cluster headache mean, and what options exist when standard treatments fail?

Refractory chronic cluster headache generally refers to chronic cluster headache that continues despite appropriate trials of standard acute and preventive therapies.⁴ In plain terms: you and your clinicians have tried the usual evidence-based options, and the attacks remain disabling.⁴

When that happens, some people are referred to specialized headache centers to discuss advanced therapies, including invasive neuromodulation approaches.⁴ These discussions should include careful diagnosis confirmation, documentation of treatments already tried, and a clear review of benefits, risks, and device availability.⁴

What is occipital nerve stimulation, and what do results and risks look like?

Occipital nerve stimulation (ONS) is an implanted therapy that delivers stimulation near the occipital nerves at the back of the head.⁴ It is generally considered for medically intractable chronic cluster headache in specialized centers, not as an early-line treatment.⁴

Evidence includes randomized trial data such as the ICON study, along with longer-term cohort and case series experience.⁴²² ONS can help some people, but device-related issues are common, including lead migration, cable problems, battery depletion, and infection.⁴ A realistic conversation with a specialist usually centers on probabilities, complication management, and what “success” would look like for you, for example fewer attacks, lower intensity, or less reliance on rescue treatments.⁴²²

What is sphenopalatine ganglion stimulation, and what’s the current availability story?

Sphenopalatine ganglion (SPG) stimulation is an implanted approach that targets a nerve hub connected to facial autonomic pathways involved in cluster headache symptoms.¹⁰ A randomized sham-controlled study (Pathway CH-1) reported higher odds of pain relief at 15 minutes for stimulated attacks compared with sham.²³

Availability has been complicated. The EAN guideline notes that the original manufacturer and sponsor of the key studies went out of business in 2018, and it references efforts by a new company to provide the therapy.⁴ A published reply in The Lancet Neurology discusses the disruption in care after sponsor closure, highlighting that real-world access can change even when clinical evidence exists.²⁴ If SPG stimulation comes up, it’s worth asking not only “Does it work for some people,” but also, “Is it currently available, who maintains it, and what happens if a company exits the market.”⁴²⁴

What is deep brain stimulation for cluster headache, and when is it even considered?

Deep brain stimulation (DBS) for cluster headache has most often targeted the posterior inferior hypothalamus region, based on imaging and mechanistic research linking this area to attacks.⁴⁹ DBS is generally discussed only for highly selected, refractory chronic cluster headache cases in expert centers, after less invasive options have been tried.⁴

This is because DBS carries serious risks. The EAN guideline estimates the risk of bleeding with DBS at approximately 2% and notes that death has been reported in this context.⁴ A randomized placebo-controlled double-blind trial with an open extension has been published, but overall evidence is limited and decisions are highly individualized.⁴²⁵ If DBS is being considered, the most helpful stance is slow and thorough: confirm diagnosis, confirm that standard therapies were truly optimized, ask about center experience, and ask how risks are reduced and managed.⁴²⁵

What daily tracking can make clinic visits more productive?

A simple attack diary can turn a chaotic experience into clearer signals your clinician can act on. Many guidelines and expert reviews emphasize the importance of documenting frequency, timing, response, and side effects to guide treatment adjustments.⁴¹²

If you want a practical structure, track:
 • Start time and end time of each attack¹
 • Peak intensity (for example 0–10) and where the pain was located¹
 • Same-side symptoms (tearing, nasal congestion, eyelid droop, facial sweating)¹
 • What you used acutely (oxygen, triptan, device), how fast you used it, and how well it worked⁴⁷
 • Any side effects, especially chest symptoms, severe dizziness, or new neurologic symptoms⁷¹²

What questions can I bring to my medical team about cluster headache treatment plans?

It helps to walk in with questions that match the real decision points. These questions are educational and planning-focused, not self-prescribing.

Consider asking:
 • Does my pattern meet ICHD-3 criteria for cluster headache, or is another TAC on the table?¹
 • Do you recommend MRI for me, and if so, what are we specifically trying to rule out?¹²¹³
 • For my acute plan, what is first-line for me, oxygen, sumatriptan, or both, and what is the fastest way to start treatment at home or at work?⁴⁵⁶⁷
 • If verapamil is recommended, what is the titration plan, and what ECG monitoring schedule will you use?⁴¹⁵¹⁶
 • What bridge strategy makes sense during the first days of this cluster period, oral steroids, an injection, or something else?⁴¹⁷¹⁸
 • If my condition is chronic and refractory, when would you refer to a specialized center to discuss ONS, SPG stimulation, or DBS?⁴²²²³

How can care partners help during an attack and between attacks?

During an attack, practical support often matters more than conversation. Helping someone get to their oxygen setup quickly, preparing a quiet and safe space, timing treatments, and tracking the outcome can reduce the burden on the person in pain.⁴⁶

Between attacks, care partners can help with logistics that keep treatment consistent: ensuring oxygen supplies are refilled, helping organize medication schedules and ECG appointments if verapamil is used, and supporting follow-up when side effects or access barriers show up.⁴¹² For emotional support, it’s okay to name the truth gently: repeated severe pain can wear a person down. Encouraging connection with headache specialty care and mental health support when needed is part of whole-person care.¹¹¹²
SAFETY NOTE
If headache symptoms are urgent, sudden, or severe, seek emergency care. Go to an emergency room or call emergency services if there is a sudden “worst headache,” fainting, confusion, high fever, stiff neck, weakness or numbness on one side, trouble speaking, trouble seeing, or trouble walking.²⁶

GLOSSARY
Attack: A single episode of headache pain with symptoms that starts and ends, for example one cluster headache episode lasting minutes to hours.
Autonomic symptoms: Body changes controlled by the automatic nervous system, like tearing, a runny nose, facial sweating, eyelid swelling, or a drooping eyelid.
Bout (cluster period): A stretch of days to months when cluster headache attacks occur repeatedly, often followed by remission.
Bridge treatment: A short-term treatment used to reduce attacks quickly while a longer-term preventive treatment is being started or adjusted.
CGRP: Calcitonin gene-related peptide, a signaling molecule involved in pain pathways and blood vessel and nerve activity.
Chronic cluster headache: Cluster headache that continues for at least one year without remission, or with remissions shorter than three months.
ECG (EKG): A heart rhythm test that records the electrical activity of the heart; used to monitor for rhythm or conduction problems.
Episodic cluster headache: Cluster headache occurring in bouts that are separated by pain-free remissions lasting at least three months.
Greater occipital nerve block: An injection near the occipital nerve region, often using a steroid, intended to reduce attack frequency for a period of time.
Hypothalamus: A deep brain region involved in body rhythms and autonomic control; linked to cluster headache timing and attack biology.
ICHD-3: International Classification of Headache Disorders, 3rd edition, the main diagnostic framework used worldwide.
MRI: Magnetic resonance imaging, a scan that creates detailed images of the brain and surrounding structures.
Neuromodulation: Therapy that changes nerve activity using stimulation, either external devices or implanted systems.
Occipital nerve stimulation (ONS): An implanted device that stimulates occipital nerves, sometimes used for medically intractable chronic cluster headache.
Posterior inferior hypothalamus: A specific region near the hypothalamus that has been targeted in some DBS approaches for refractory cluster headache.
Refractory: A term used when standard evidence-based treatments have been tried appropriately but symptoms remain disabling.
Sphenopalatine ganglion (SPG): A nerve hub connected to facial autonomic pathways; targeted in some implanted treatments for cluster headache.
Subcutaneous: Given by injection under the skin.
Sumatriptan: A triptan medicine used to stop acute attacks, often as an injection for cluster headache due to speed.
Trigeminal nerve: A major facial nerve involved in sensation and pain signaling from the face and head.
Trigeminal autonomic cephalalgias (TACs): A group of headache disorders with one-sided head pain and same-side autonomic symptoms, including cluster headache.
Verapamil: A medication often used as a preventive treatment for cluster headache; it can affect heart rhythm and requires monitoring.
Vagus nerve stimulation (nVNS): A non-implanted device-based therapy applied externally, intended to influence vagus nerve pathways involved in headache biology.

REFERENCES
1. International Headache Society. ICHD-3: 3.1 Cluster headache. https://ichd-3.org/3-trigeminal-autonomic-cephalalgias/3-1-cluster-headache/(https://ichd-3.org/3-trigeminal-autonomic-cephalalgias/3-1-cluster-headache/?utm_source=chatgpt.com)
2. International Headache Society. ICHD-3: 3.1.1 Episodic cluster headache. https://ichd-3.org/3-trigeminal-autonomic-cephalalgias/3-1-cluster-headache/3-1-1-episodic-cluster-headache/(https://ichd-3.org/3-trigeminal-autonomic-cephalalgias/3-1-cluster-headache/3-1-1-episodic-cluster-headache/?utm_source=chatgpt.com)
3. International Headache Society. ICHD-3: 3.1.2 Chronic cluster headache. https://ichd-3.org/3-trigeminal-autonomic-cephalalgias/3-1-cluster-headache/3-1-2-chronic-cluster-headache/(https://ichd-3.org/3-trigeminal-autonomic-cephalalgias/3-1-cluster-headache/3-1-2-chronic-cluster-headache/?utm_source=chatgpt.com)
4. May A, Evers S, Goadsby PJ, et al. European Academy of Neurology guidelines on the treatment of cluster headache. Eur J Neurol. 2023;30(10):2955-2979. https://www.uems-neuroboard.org/web/images/docs/exam/2024/papers/06-EAN-guideline-cluster-headache2023.pdf(https://www.uems-neuroboard.org/web/images/docs/exam/2024/papers/06-EAN-guideline-cluster-headache2023.pdf?utm_source=chatgpt.com)
5. Robbins MS, Starling AJ, Pringsheim TM, Becker WJ, Schwedt TJ. Treatment of cluster headache: the American Headache Society evidence-based guidelines. Headache. 2016;56(7):1093-1106. https://doi.org/10.1111/head.12866()
6. Cohen AS, Burns B, Goadsby PJ. High-flow oxygen for treatment of cluster headache: a randomized trial. JAMA. 2009;302(22):2451-2457. https://doi.org/10.1001/jama.2009.1855()
7. U.S. Food and Drug Administration. IMITREX (sumatriptan) injection, prescribing information. 2025. https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/020080s055lbl020132s031lbl.pdf(https://www.accessdata.fda.gov/drugsatfda_docs/label/2025/020080s055lbl020132s031lbl.pdf?utm_source=chatgpt.com)
8. U.S. Food and Drug Administration. EMGALITY (galcanezumab-gnlm) prescribing information. 2019. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/761063s003lbl.pdf(https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/761063s003lbl.pdf?utm_source=chatgpt.com)
9. May A, Bahra A, Büchel C, Frackowiak RSJ, Goadsby PJ. Hypothalamic activation in cluster headache attacks. Lancet. 1998;352(9124):275-278. https://doi.org/10.1016/S0140-6736(98)02470-2()
10. Costa A, Pucci E, Antonaci F, et al. The neuropharmacology of cluster headache and other trigeminal autonomic cephalalgias. Expert Rev Neurother. 2015;15(1):75-90. https://pmc.ncbi.nlm.nih.gov/articles/PMC4812802/(https://pmc.ncbi.nlm.nih.gov/articles/PMC4812802/?utm_source=chatgpt.com)
11. Wei DY, Yuan Ong JJ, Goadsby PJ. Cluster headache: epidemiology, pathophysiology, clinical features, and diagnosis. Ann Indian Acad Neurol. 2018;21(Suppl 1):S3-S8. https://journals.lww.com/annalsofian/fulltext/2018/21001/cluster_headache__epidemiology%2C_pathophysiology%2C.2.aspx(https://journals.lww.com/annalsofian/fulltext/2018/21001/cluster_headache__epidemiology%2C_pathophysiology%2C.2.aspx?utm_source=chatgpt.com)
12. Ray JC, Woldeamanuel YW. Cluster headache in adults. Aust Prescr. 2022;45(5):165-171. https://australianprescriber.tg.org.au/articles/cluster-headache-in-adults.html(https://australianprescriber.tg.org.au/articles/cluster-headache-in-adults.html?utm_source=chatgpt.com)
13. Bianco F, Valente M, Bastianello S, et al. Neuroimaging in cluster headache and other trigeminal autonomic cephalalgias. J Headache Pain. 2012;13(1):3-10. https://pmc.ncbi.nlm.nih.gov/articles/PMC3253152/(https://pmc.ncbi.nlm.nih.gov/articles/PMC3253152/?utm_source=chatgpt.com)
14. The Sumatriptan Cluster Headache Study Group. Treatment of acute cluster headache with sumatriptan. N Engl J Med. 1991;325(5):322-326. https://doi.org/10.1056/NEJM199108013250505()
15. Cohen AS, Matharu MS, Goadsby PJ. Electrocardiographic abnormalities in patients with cluster headache on verapamil therapy. Neurology. 2007;69(7):668-675. https://pubmed.ncbi.nlm.nih.gov/17698788/(https://pubmed.ncbi.nlm.nih.gov/17698788/?utm_source=chatgpt.com)
16. Koppen H, Stolwijk-Swüste JM, Rijsman RM, et al. Cardiac monitoring of high-dose verapamil in cluster headache: an expert panel’s view. Cephalalgia. 2016;36(12):1108-1112. https://doi.org/10.1177/0333102416631968()
17. Leroux E, Valade D, Taifas I, et al. Suboccipital steroid injections for transitional treatment of patients with more than two cluster headache attacks per day: a randomised, double-blind, placebo-controlled trial. Lancet Neurol. 2011;10(10):891-897. https://doi.org/10.1016/S1474-4422(11)70186-7()
18. Ambrosini A, Vandenheede M, Rossi P, et al. Suboccipital injection with a mixture of rapid- and long-acting steroids in cluster headache: a double-blind placebo-controlled study. Pain. 2005;118(1-2):92-96. https://doi.org/10.1016/j.pain.2005.07.015()
19. European Medicines Agency. Emgality: EPAR overview. https://www.ema.europa.eu/en/medicines/human/EPAR/emgality(https://www.ema.europa.eu/en/medicines/human/EPAR/emgality?utm_source=chatgpt.com)
20. European Medicines Agency. Emgality: EPAR refusal public assessment report (cluster headache extension). 2020. https://www.ema.europa.eu/en/documents/variation-report/emgality-h-c-04648-x-0004-epar-refusal-public-assessment-report_en.pdf(https://www.ema.europa.eu/en/documents/variation-report/emgality-h-c-04648-x-0004-epar-refusal-public-assessment-report_en.pdf?utm_source=chatgpt.com)
21. Eli Lilly Canada. Emgality (galcanezumab) now approved in Canada for episodic cluster headache. 2021. https://www.lilly.com/en-CA/news/press-releases/21.02.25-Emgality-galcanezumab-approved-Canada-episodic-cluster-headache(https://www.lilly.com/en-CA/news/press-releases/21.02.25-Emgality-galcanezumab-approved-Canada-episodic-cluster-headache?utm_source=chatgpt.com)
22. Wilbrink LA, de Coo IF, Doesborg PGG, et al. Safety and efficacy of occipital nerve stimulation for attack prevention in medically intractable chronic cluster headache (ICON): a randomised, double-blind, multicentre, phase 3, electrical dose-controlled trial. Lancet Neurol. 2021;20(7):515-525. https://doi.org/10.1016/S1474-4422(21)00101-0()
23. Schoenen J, Jensen RH, Lantéri-Minet M, et al. Stimulation of the sphenopalatine ganglion (SPG) for cluster headache treatment: Pathway CH-1, a randomized, sham-controlled study. Cephalalgia. 2013;33(10):816-830. https://doi.org/10.1177/0333102412473667()
24. Goadsby PJ, Rezai AR, Dodick DW. The need for continued care after sponsor closure: authors’ reply. Lancet Neurol. 2020;19(3):205-206. https://doi.org/10.1016/S1474-4422(20)30024-7()
25. Fontaine D, Lazorthes Y, Mertens P, et al. Safety and efficacy of deep brain stimulation in refractory cluster headache: a randomized placebo-controlled double-blind trial followed by a 1-year open extension. J Headache Pain. 2010;11(1):23-31. https://doi.org/10.1007/s10194-009-0174-1()
26. Mayo Clinic. Headache: when to see a doctor. https://www.mayoclinic.org/symptoms/headache/basics/when-to-see-doctor/sym-20050800(https://www.mayoclinic.org/symptoms/headache/basics/when-to-see-doctor/sym-20050800?utm_source=chatgpt.com)

Question 2

TRIGMENAL NEUROPATHIC PAIN

Accepted Answer

What is trigeminal neuropathic pain?

Trigeminal neuropathic pain is facial or oral pain linked to injury or disease affecting the trigeminal nerve or its pathways. “Neuropathic pain” has a specific meaning: pain caused by a lesion or disease of the somatosensory nervous system, the network that carries touch, temperature, and pain signals.¹

In the ICHD-3 classification, “painful trigeminal neuropathy” is facial pain in one or more trigeminal branches that is caused by another disorder and is a sign of neural damage.² The baseline pain is usually continuous or near-continuous, often described as burning, squeezing, or pins-and-needles, and short bursts of sharper pain can occur but are not the main pattern.²

Which parts of the face can be involved, and why do clinicians talk about V1, V2, and V3?

The trigeminal nerve is commonly described in three divisions because symptoms often follow these territories. V1 generally covers the forehead and eye region, V2 covers the cheek and upper jaw, and V3 covers the lower jaw and chin.²⁵

Clinicians use these territories like a map. A clear, consistent location pattern can support a neuropathic diagnosis, while a shifting or poorly localized pattern can suggest other causes such as dental disease, temporomandibular disorders, sinus disease, headache disorders, or mixed pain conditions.⁵

How is trigeminal neuropathic pain different from trigeminal neuralgia?

Painful trigeminal neuropathy is usually steady or near-steady and often comes with sensory changes that hint the nerve is not working normally, such as numbness, reduced sensation, tingling, or pain with light touch.²⁵ The ICHD-3 description emphasizes that the continuous, burning or squeezing quality is a key differentiator from trigeminal neuralgia subtypes.²

Trigeminal neuralgia is classically defined by recurrent brief attacks of severe, electric shock-like pain, abrupt in onset and ending quickly, often triggered by harmless touch.⁴ Many people with trigeminal neuralgia can have background pain too, but the hallmark is still those short, shock-like paroxysms.⁴ Because the treatments and the workup can differ, careful phenotyping, meaning clearly describing the pain pattern and sensory findings, matters.⁸

What causes trigeminal neuropathic pain?

There are several pathways into trigeminal neuropathic pain. One major category is trauma to trigeminal branches, which can include facial injuries and iatrogenic injury, meaning unintended nerve injury related to medical or dental procedures.³⁶⁷

In ICHD-3, “painful post-traumatic trigeminal neuropathy” is defined as unilateral or bilateral facial or oral pain following and caused by trauma to the trigeminal nerve, with symptoms and/or clinical signs of trigeminal nerve dysfunction.³ Other subtypes exist where trigeminal neuropathic pain is attributed to other causes, such as multiple sclerosis plaques, space-occupying lesions, or systemic disease, and the cause influences what tests are considered.²

What does trigeminal neuropathic pain feel like in daily life?

People often describe a persistent burn, rawness, tight pressure, pins-and-needles, or an “electric hum” under the skin.²⁵ The pain can stay in a small patch, or it can spread along a branch distribution, and it may flare with chewing, speaking, toothbrushing, shaving, wind on the face, or prolonged facial contact like masks or phone use.⁵⁶

A particularly frustrating feature is sensory mismatch: the same area can feel numb and painful at the same time, or light touch can feel sharply painful.²⁶ This is not a character flaw or “overreacting.” It fits what clinicians expect when damaged sensory fibers and central pain networks become sensitized after injury.⁶⁷

What are allodynia and hyperalgesia, and why do they matter?

Allodynia means pain caused by something that normally should not hurt, like gentle touch or a cool breeze. Hyperalgesia means an increased response to something that usually is painful, like a firm pinch. These are common neuropathic features and can show up in trigeminal neuropathic pain.²⁶

They matter because they help confirm that the pain is being generated or amplified within sensory nerve pathways, not purely from inflammation or mechanical strain.²⁵⁶ They also help guide treatment selection and expectations, since neuropathic pain often responds differently than typical “injury pain.”¹⁹

How is trigeminal neuropathic pain diagnosed?

Diagnosis is primarily clinical. That means a careful symptom story plus a targeted sensory exam of the face and oral tissues, looking for a pain distribution consistent with trigeminal branches and signs of sensory dysfunction.²⁵⁷ Clinicians often document both negative signs, such as reduced sensation, and positive signs, such as touch-evoked pain.²⁶

Classification frameworks help teams use consistent language. ICHD-3 provides criteria and descriptions for painful trigeminal neuropathy and painful post-traumatic trigeminal neuropathy.²³ The International Classification of Orofacial Pain (ICOP) aligns with ICHD principles and is widely used in orofacial pain practice to classify neuropathic facial pain conditions in a structured way.⁵

Who typically evaluates trigeminal neuropathic pain?

Evaluation can involve more than one specialty. Neurology is common, but so are orofacial pain specialists, pain medicine clinicians, ENT, and dental specialists with training in complex facial pain.⁵⁷

This multi-lens approach is often helpful because facial pain can sit at the intersection of nerve injury, dental structures, jaw mechanics, and headache disorders. ICOP was created in part to reduce confusion and improve consistent diagnosis across disciplines.⁵

When might imaging like MRI be discussed?

Imaging is not automatically required for every person, but clinicians often consider MRI when the presentation is atypical, progressive, involves multiple cranial nerves, includes concerning neurologic signs, or when they need to rule out secondary causes that can affect trigeminal pathways.²⁸

If the symptom pattern overlaps with trigeminal neuralgia, MRI is frequently used to evaluate for secondary trigeminal neuralgia and to support planning.⁸ Even when imaging is normal, it can still be valuable because it helps confirm what is not happening, which can reduce uncertainty and narrow the treatment plan.⁸

What is the role of sensory testing beyond a bedside exam?

Many clinicians start with a bedside sensory exam, mapping light touch, pinprick, and temperature differences side-to-side. When needed, specialized centers may use additional tests to document trigeminal afferent function, depending on the suspected condition and local availability.⁸

The EAN trigeminal neuralgia guideline notes that trigeminal reflex testing and evoked potentials can help detect trigeminal afferent damage in different neuropathic facial pain conditions, especially when MRI is unavailable or when diagnostic uncertainty remains.⁸ This is not required for everyone, but it can be part of a deeper workup in complex cases.⁸

Why can trigeminal neuropathic pain become long lasting?

Nerves heal slowly, and sometimes healing is incomplete. After nerve injury, damaged fibers can generate abnormal signals, and the spinal trigeminal system and broader pain networks can become more reactive over time. This combination can sustain pain even after the original tissue trigger has resolved.⁶⁷

Consensus guidance on trigeminal nerve injuries emphasizes the importance of structured diagnosis, follow-up, and documentation because symptoms can evolve.⁷ Some people improve over time, others develop persistent pain with functional impacts like avoiding eating on one side, difficulty with dental hygiene, or fear of touch-triggered flares.⁶⁷

What treatments are commonly tried first?

Most first-line approaches follow broader neuropathic pain evidence and guidelines, adapted to the person’s facial pain pattern and tolerability. A major evidence-based review supports first-line use of tricyclic antidepressants, SNRIs, and gabapentinoids for neuropathic pain in adults.⁹ NICE guidance similarly recommends offering a choice of amitriptyline, duloxetine, gabapentin, or pregabalin as initial treatment for neuropathic pain, with the note that trigeminal neuralgia is handled separately.¹⁰

In trigeminal neuropathic pain, clinicians often start with one medicine, titrate carefully, and assess both pain and function, not just a number on a pain scale.⁹¹⁰ Because sedation, dizziness, dry mouth, constipation, mood effects, or cognitive slowing can happen, the best plan is usually stepwise, with clear goals and a defined “trial window” decided with the prescribing clinician.⁹¹⁰

How do clinicians decide between gabapentin, pregabalin, amitriptyline, or duloxetine?

These medicines act on different parts of pain signaling. Gabapentin and pregabalin reduce nerve excitability, often helping with burning and shooting neuropathic qualities. Amitriptyline and duloxetine influence pain modulation pathways that connect mood, sleep, and pain processing, which can matter when pain disrupts rest and resilience.⁹¹⁰

Choice often depends on your health history, other medicines, side effect risk, sleep pattern, anxiety or depression symptoms, and whether daytime alertness is essential for work or safety. NICE recommends switching among these options if the first choice is not effective or not tolerated.¹⁰ This is decision-support territory: your clinician weighs benefit versus burden, then adjusts with you rather than declaring any single “best drug” for everyone.⁹¹⁰

What about topical treatments or local strategies for focal facial neuropathic pain?

For some neuropathic pain conditions, topical lidocaine is used to reduce surface sensitivity and touch-evoked pain. Large neuropathic pain guidance often discusses topical options as part of a layered plan, especially when the pain is localized.⁹

In trigeminal neuropathic pain, the practical question is whether the painful area is accessible and well-defined, and whether touch-evoked flares are a major driver of disability. When topical or local strategies are considered, it is reasonable to ask what symptom they are targeting, constant pain, touch pain, oral sensitivity, or flare prevention, and how you will measure benefit.⁷⁹

What care pathways are recommended after suspected trigeminal nerve injury?

If the pain started after a clear nerve insult, such as dental trauma or facial injury, many experts emphasize early recognition, careful sensory documentation, and follow-up that tracks change over time.⁶⁷ The goal is not only symptom relief, but also clarity about whether nerve function is improving, stable, or worsening.⁷

A recent Delphi-based consensus guideline on trigeminal nerve injuries provides recommendations and flowcharts addressing training, diagnosis, treatment considerations, and follow-up care.⁷ It also highlights a real-world truth: evidence for many treatments is limited, so structured monitoring and shared decision-making become even more important.⁷

When do clinicians consider neuromodulation for trigeminal neuropathic pain?

Neuromodulation refers to therapies that change nerve or brain activity through electrical stimulation. It spans non-invasive approaches, minimally invasive procedures, and implanted systems.¹¹ In trigeminal neuropathic pain, neuromodulation is generally discussed when pain remains severe and disabling despite appropriate medication trials and when the diagnosis is well supported.⁷¹¹

This step is usually best handled in specialized centers because treatment selection depends on the pain pattern, location, prior procedures, sensory deficits, psychological burden, and risk tolerance. The 2021 Lancet review on neuromodulation emphasizes that patient selection, realistic goals, and long-term follow-up planning are central to neuromodulation success.¹¹

What is motor cortex stimulation, and what does evidence suggest for neuropathic orofacial pain?

Motor cortex stimulation (MCS) is an implanted neurosurgical therapy that places an electrode over the motor cortex to modulate pain networks. It has been used in some refractory neuropathic pain syndromes, including chronic neuropathic orofacial pain.¹²

A systematic review and meta-analysis of invasive MCS in chronic neuropathic orofacial pain found substantial average pain relief across included studies, while also noting heterogeneity, meaning results vary by condition type, technique, and patient factors.¹² This is a key point for decision-making: MCS can help some people, but outcomes are not uniform, and careful counseling is essential.¹²

What is peripheral nerve stimulation for trigeminal neuropathic pain?

Peripheral nerve stimulation (PNS) uses implanted electrodes near peripheral nerves to reduce pain signaling. In trigeminal neuropathic pain, this may involve stimulation near supraorbital, infraorbital, or other facial nerve branches depending on the pain distribution.¹³

A systematic review focused on implantable PNS for trigeminal neuropathic pain concluded that evidence is still limited but suggests PNS may be an option for intractable trigeminal neuropathic pain, with outcomes and complications varying across reports.¹³ In practice, discussions often center on whether the painful area is well localized, whether prior surgery or scarring complicates placement, and what device maintenance and revision risks look like.¹¹¹³

Where does deep brain stimulation fit for pain, and what targets are used?

Deep brain stimulation (DBS) for chronic pain is typically reserved for highly selected, treatment-refractory cases in specialized centers. It is not a first-line therapy for trigeminal neuropathic pain, and it is often considered only after less invasive options, including medication optimization and sometimes peripheral or cortical stimulation approaches, have been explored.¹¹¹⁴¹⁵

DBS targets used historically and in modern reviews include sensory thalamic nuclei and the periaqueductal and periventricular gray (PAG/PVG) for pain modulation, with more recent exploration of targets linked to the emotional and suffering dimension of pain such as the anterior cingulate cortex.¹⁴¹⁵ Evidence across pain etiologies is mixed, and reviews emphasize variability in outcomes and the need for careful patient selection and standardized approaches.¹⁴¹⁵

What are the major risks and tradeoffs of procedures and implanted devices?

For any invasive option, risks include infection, bleeding, device malfunction, lead migration, and the possibility of revision surgery. The more central the target, generally the higher the procedural complexity and risk.¹¹¹⁴

Tradeoffs are not only medical, they are practical. Implanted neuromodulation requires follow-up, programming visits, battery management, and a plan for troubleshooting. The Lancet neuromodulation review stresses that long-term outcomes depend not just on implantation, but on sustained follow-up systems and clear goals for function and quality of life.¹¹

What can I track to help my medical team tailor care?

Tracking is not busywork. It is a way to pull your experience out from under the mask of “it hurts all the time” and show the pattern in daylight. That pattern helps clinicians choose, adjust, or stop treatments safely.⁷⁹

Before listing, these bullets cover the most decision-relevant details: distribution, sensory changes, triggers, reminders of the initiating event, and measurable functional impact.
 • Pain map: exact areas involved, side, and whether it fits a trigeminal division pattern.²⁵
 • Pain quality: burning, squeezing, pins-and-needles, aching, stabbing, electric, and whether it changes over weeks.²
 • Sensory changes: numbness, reduced sensation, touch-evoked pain, cold sensitivity, oral sensitivity, and whether gentle touch triggers flares.²⁶
 • Function: chewing, speaking, toothbrushing, shaving, wind exposure, mask contact, sleep disruption, and social avoidance due to pain.⁵⁶
 • Timeline: onset date, what happened just before onset, dental work, facial injury, infection, or neurologic symptoms.³⁶
 • Treatment trials: medicine name, dose changes, side effects, and what improved, pain intensity, flare frequency, sleep, or daily function.⁹¹⁰

What questions can I bring to my next appointment?

Good questions keep the conversation honest and specific. They lift the veil: What exactly are we treating, what is the evidence, and what is the next step meant to accomplish?

Before listing, these questions are designed to support shared decision-making without pushing you toward any single treatment.
 • Does my pattern fit painful trigeminal neuropathy or painful post-traumatic trigeminal neuropathy, and what findings support that?²³
 • Do you see trigeminal nerve dysfunction on exam, and should we document it systematically over time?³⁷
 • Do I need MRI or other testing, and what specific condition are we trying to rule out?²⁸
 • What is our stepwise medication plan, what is a fair trial length, and what outcome measures will we use, pain, sleep, eating, oral care, or work function?⁹¹⁰
 • If pain remains refractory, which neuromodulation options are realistic here, peripheral nerve stimulation, motor cortex stimulation, or DBS, and what evidence supports each for my specific pattern?¹¹¹²¹³¹⁴

When should facial pain be treated as an emergency?

Neuropathic facial pain is often chronic, but sudden changes can signal something that needs urgent evaluation. Seek emergency care if facial pain is sudden and extreme, or if it comes with new neurologic symptoms such as weakness, facial droop, confusion, trouble speaking, vision changes, fainting, or new difficulty walking.²⁸

Also seek urgent care if there is high fever, rapidly worsening swelling, severe dental or facial infection signs, or if you feel unsafe. If you already have an implanted device and you develop fever, wound redness or drainage, severe new headache, or sudden neurologic changes, urgent evaluation is important.¹¹¹⁴
SAFETY NOTE
This page is educational and can’t diagnose or treat. If symptoms are urgent, sudden, or severe, or you have new neurologic symptoms, fever, rapidly worsening swelling, or you feel unsafe, seek emergency care right away.

GLOSSARY
Allodynia: Pain triggered by something that normally should not hurt, such as light touch.
Anterior Cingulate Cortex: A brain region involved in the emotional and attention aspects of pain, sometimes explored as a DBS target for refractory pain.
Deep Brain Stimulation: A therapy that uses implanted electrodes to deliver electrical stimulation to specific brain targets to change pain-related circuit activity.
Hyperalgesia: Increased pain from something that is usually painful.
ICHD-3: International Classification of Headache Disorders, 3rd edition, a standardized system used to classify headache and certain facial pain disorders.
ICOP: International Classification of Orofacial Pain, a standardized framework for diagnosing and classifying orofacial pain conditions.
Motor Cortex Stimulation: An implanted neuromodulation approach that stimulates the motor cortex to reduce certain chronic neuropathic pain states.
Neuromodulation: Use of electrical stimulation to change nerve or brain signaling involved in pain.
Neuropathic Pain: Pain caused by a lesion or disease of the somatosensory nervous system.
PAG/PVG: Periaqueductal gray and periventricular gray, brain regions involved in pain modulation that have been used as DBS targets in some chronic pain cases.
Peripheral Nerve Stimulation: An implanted approach that stimulates peripheral nerves near the pain area to reduce pain signaling.
Somatosensory Nervous System: The nerve network that carries touch, temperature, and pain information.
Trigeminal Neuralgia: A disorder marked by brief, severe, electric shock-like facial pain attacks, often triggered by light touch.
Trigeminal Neuropathic Pain: Neuropathic facial or oral pain linked to trigeminal nerve injury or disease, often continuous and associated with sensory changes.
Trigeminal Nerve: The main sensory nerve of the face, commonly described in three divisions that map to different facial regions.

REFERENCES
1. International Association for the Study of Pain. IASP Terminology: Neuropathic pain. https://www.iasp-pain.org/resources/terminology/(https://www.iasp-pain.org/resources/terminology/?utm_source=chatgpt.com)
2. International Headache Society. ICHD-3: 13.1.2 Painful trigeminal neuropathy. https://ichd-3.org/13-painful-cranial-neuropathies-and-other-facial-pains/13-1-trigeminal-neuralgia/13-1-2-painful-trigeminal-neuropathy/(https://ichd-3.org/13-painful-cranial-neuropathies-and-other-facial-pains/13-1-trigeminal-neuralgia/13-1-2-painful-trigeminal-neuropathy/?utm_source=chatgpt.com)
3. International Headache Society. ICHD-3: 13.1.2.3 Painful post-traumatic trigeminal neuropathy. https://ichd-3.org/13-painful-cranial-neuropathies-and-other-facial-pains/13-1-trigeminal-neuralgia/13-1-2-painful-trigeminal-neuropathy/13-1-2-3-painful-post-traumatic-trigeminal-neuropathy/(https://ichd-3.org/13-painful-cranial-neuropathies-and-other-facial-pains/13-1-trigeminal-neuralgia/13-1-2-painful-trigeminal-neuropathy/13-1-2-3-painful-post-traumatic-trigeminal-neuropathy/?utm_source=chatgpt.com)
4. International Headache Society. ICHD-3: 13.1.1 Trigeminal neuralgia. https://ichd-3.org/13-painful-cranial-neuropathies-and-other-facial-pains/13-1-trigeminal-neuralgia/13-1-1-classical-trigeminal-neuralgia/(https://ichd-3.org/13-painful-cranial-neuropathies-and-other-facial-pains/13-1-trigeminal-neuralgia/13-1-1-classical-trigeminal-neuralgia/?utm_source=chatgpt.com)
5. International Headache Society. International Classification of Orofacial Pain, 1st edition (ICOP). Cephalalgia. 2020;40(2):129-221. doi:10.1177/0333102419893823. https://journals.sagepub.com/doi/pdf/10.1177/0333102419893823(https://journals.sagepub.com/doi/pdf/10.1177/0333102419893823?utm_source=chatgpt.com)
6. Park HJ, Ahn JM, Ryu JW. Post-Traumatic Trigeminal Neuropathic Pain: A Narrative Review of Understanding, Management, and Prognosis. Biomedicines. 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC11428572/(https://pmc.ncbi.nlm.nih.gov/articles/PMC11428572/?utm_source=chatgpt.com)
7. Van der Cruyssen F, Palla B, Jacobs R, et al. Consensus guidelines on training, diagnosis, treatment and follow-up care of trigeminal nerve injuries. Int J Oral Maxillofac Surg. 2024. https://pubmed.ncbi.nlm.nih.gov/37365073/(https://pubmed.ncbi.nlm.nih.gov/37365073/?utm_source=chatgpt.com)
8. Bendtsen L, Zakrzewska JM, Abbott J, et al. European Academy of Neurology guideline on trigeminal neuralgia. Eur J Neurol. 2019;26(6):831-849. https://www.uems-neuroboard.org/web/images/docs/exam/2021/Guideline-Papers/EAN-guideline-trigeminal-neuralgia-Bendtsen2019.pdf(https://www.uems-neuroboard.org/web/images/docs/exam/2021/Guideline-Papers/EAN-guideline-trigeminal-neuralgia-Bendtsen2019.pdf?utm_source=chatgpt.com)
9. Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015;14(2):162-173. doi:10.1016/S1474-4422(14)70251-0. https://pmc.ncbi.nlm.nih.gov/articles/PMC4493167/(https://pmc.ncbi.nlm.nih.gov/articles/PMC4493167/?utm_source=chatgpt.com)
10. National Institute for Health and Care Excellence. Neuropathic pain in adults: pharmacological management in non-specialist settings (CG173), Recommendations. https://www.nice.org.uk/guidance/cg173/chapter/1-recommendations(https://www.nice.org.uk/guidance/cg173/chapter/1-recommendations?utm_source=chatgpt.com)
11. Knotkova H, Hamani C, Sivanesan E, et al. Neuromodulation for chronic pain. Lancet. 2021;397(10289):2111-2124. doi:10.1016/S0140-6736(21)00794-7. https://pubmed.ncbi.nlm.nih.gov/34062145/(https://pubmed.ncbi.nlm.nih.gov/34062145/?utm_source=chatgpt.com)
12. Henssen D, Kurt E, Kozicz T, et al. Motor cortex stimulation in chronic neuropathic orofacial pain syndromes: a systematic review and meta-analysis. Sci Rep. 2020;10:Article. https://pmc.ncbi.nlm.nih.gov/articles/PMC7189245/(https://pmc.ncbi.nlm.nih.gov/articles/PMC7189245/?utm_source=chatgpt.com)
13. Ni Y, Winter A, Mukhdomi T, et al. Implantable Peripheral Nerve Stimulation for Trigeminal Neuropathic Pain: A Systematic Review. Neuromodulation. 2021. https://pubmed.ncbi.nlm.nih.gov/34008282/(https://pubmed.ncbi.nlm.nih.gov/34008282/?utm_source=chatgpt.com)
14. Pagano RL, Green A, Aziz T. Translational aspects of deep brain stimulation for chronic pain. Front Pain Res. 2023;4:1084701. https://www.frontiersin.org/journals/pain-research/articles/10.3389/fpain.2022.1084701/full(https://www.frontiersin.org/journals/pain-research/articles/10.3389/fpain.2022.1084701/full?utm_source=chatgpt.com)
15. Boccard SGJ, Pereira EAC, Moir L, et al. Deep brain stimulation for chronic pain. J Clin Neurosci. 2015. https://pubmed.ncbi.nlm.nih.gov/26122383/(https://pubmed.ncbi.nlm.nih.gov/26122383/?utm_source=chatgpt.com)

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Question 3

SELECT PHANTOM PAIN

Accepted Answer

What is phantom limb pain, and how is it different from phantom sensations and residual limb pain?

Phantom limb pain is pain that feels like it’s coming from a limb, or part of a limb, that is no longer there after an amputation.¹³ It is real pain, even though the body part is missing, and it can be burning, stabbing, cramping, squeezing, electric, or deeply aching.³⁷

It helps to separate three experiences that often get mixed together. Phantom limb sensations are non-painful feelings that the missing limb is still present, like tingling, movement, or “the foot is still there.”²³ Residual limb pain (sometimes called stump pain) is pain felt in the remaining part of the limb that is still physically present, often influenced by wounds, neuromas (irritated nerve endings), infection, swelling, or prosthetic fit issues.²³ Sorting these apart matters because the best next step can be different depending on which one is driving the distress.²³⁷

How common is phantom limb pain, and when does it usually start?

Phantom limb pain is common after limb loss, but estimates vary across studies because populations, methods, and definitions differ. A large systematic review and meta-analysis estimated that about 6 in 10 people with an amputation report phantom limb pain.⁵ Broader pain classification work and clinical reviews report a wide prevalence range, roughly 30% to 85% after amputation.⁴⁷

Timing varies, too. Many people experience phantom limb pain within the first days to weeks after amputation, while others develop it later, or notice it waxing and waning over months and years.³⁷ The course can be frustratingly uneven: some people improve steadily, some have flares during stress or poor sleep, and some have persistent pain that needs longer-term care planning.²³

Why does phantom limb pain happen, and what do we know about the mechanisms?

There isn’t one single cause. Most modern explanations involve a mix of peripheral nerve changes and central nervous system changes, meaning both the “wiring in the limb” and the brain and spinal cord networks that interpret sensation.¹⁷ After amputation, injured nerve endings can form neuromas and generate abnormal signals, and the spinal cord and brain can become more sensitive to those signals.³⁷

At the brain level, the sensory map of the missing limb doesn’t simply disappear. The nervous system keeps trying to predict and interpret input from a body part that is no longer sending normal signals, and that mismatch can contribute to pain.¹⁷ This is one reason therapies that rebuild “coherent feedback,” like mirror therapy and graded motor imagery, may help some people.¹⁸¹⁹ It is also why phantom limb pain can feel like it has a life of its own: the pain is not only about tissue damage, it can also be about how the nervous system is processing absence, memory, and threat.¹⁷

What factors raise the chance of phantom limb pain becoming persistent?

Research suggests several factors are associated with higher risk of phantom limb pain, especially persistent or severe pain, although not every study agrees on every factor. Systematic reviews commonly report that pre-amputation pain, residual limb pain after surgery, and non-painful phantom sensations are associated with phantom limb pain.⁶⁵

There are also care-pathway factors that may matter. A recent review highlights associations such as limited pre-amputation counseling and certain medical causes of amputation, alongside pain-related predictors like persistent pre-amputation pain and residual limb pain.⁶ These are not “blame” factors.
They are clues that pain prevention, early follow-up, and whole-person rehab support may reduce long-term suffering for some people.⁶²

How is phantom limb pain diagnosed, and what else needs to be ruled out?

Phantom limb pain is diagnosed based on a careful history: where the pain feels like it is, how it behaves, what triggers it, and how it relates to the amputation timeline.²³ Clinicians also ask about the prosthesis, wound healing, and whether pain is truly “phantom” versus coming from the residual limb.²³

A key part of diagnosis is checking for treatable drivers of residual limb pain that can spill over into phantom pain, such as neuroma pain, skin breakdown, infection, poor prosthetic fit, bone spurs, or ischemia (poor blood flow).²³⁷ This doesn’t mean phantom limb pain is “really just stump pain.” It means the nervous system often blends signals, and reducing ongoing residual limb irritation can sometimes reduce phantom limb pain intensity.²³⁶

What early steps after amputation can reduce suffering and support recovery?

Early care is often about building stability: controlling pain, supporting sleep, protecting the residual limb, and starting rehabilitation in a way that does not repeatedly trigger flares.³² Good prosthetic fit and residual limb skin care matter because ongoing irritation can perpetuate pain signaling.²³

It also helps to name the emotional side without making it the “cause.” Severe repeated pain can strain mood, concentration, and hope, and that burden can amplify pain sensitivity through stress physiology.¹² Education, reassurance that the pain is real, and a plan that includes both body-focused and brain-focused strategies can make treatment feel less like guessing in the dark.¹²⁷

What non-drug therapies have evidence for phantom limb pain?
Non-drug therapies are often foundational because they target how the nervous system is processing the missing limb. Evidence quality varies, and many studies are small, but some approaches consistently appear in reviews and meta-analyses.¹⁷¹⁸¹⁹

Before listing, these options focus on recalibrating the brain-body map, reducing threat signals, and improving function:
 • Mirror therapy: uses a mirror to create the visual illusion of the missing limb moving normally, which may reduce pain for some people, especially in the short term.¹⁹
 • Graded motor imagery: a structured sequence that may include left-right limb recognition, imagined movement, and mirror therapy, with systematic review evidence suggesting possible benefit, though certainty is often low.¹⁸
 • Desensitization and sensory re-education: gentle, guided exposure to touch and texture to reduce overreactive sensory responses, often used in rehab settings.²³
 • Psychological and behavioral strategies: approaches that reduce distress and improve coping can support pain control as part of multidisciplinary care, even when the pain has a strong neurologic driver.¹²

these therapies usually work best when they are consistent and coached, not when they are tried once during a crisis. If a strategy increases pain sharply, that is useful information to bring to the clinician or therapist so the plan can be adjusted rather than abandoned.¹⁸¹⁹

What medicines are commonly used, and how strong is the evidence?

Medication choices for phantom limb pain often borrow from broader neuropathic pain evidence because phantom limb pain is commonly considered a neuropathic pain condition.⁷¹⁰ Large reviews of neuropathic pain pharmacotherapy support the use of certain antidepressants (such as tricyclic antidepressants and SNRIs) and gabapentinoids (gabapentin or pregabalin) as commonly effective classes across neuropathic pain conditions.¹⁰

That said, phantom limb pain research is unconsistent, and many reviews emphasize that no single medication works reliably for everyone.¹⁷³ A realistic medication plan is stepwise: one change at a time, clear trial windows, and tracking both pain and function, like sleep, prosthetic tolerance, walking, and daily tasks.¹⁰¹¹ If you have other conditions, like kidney disease, heart rhythm issues, or fall risk, medication selection and dosing should be tailored by your clinician.¹¹

What interventional and surgical approaches can address nerve-driven post-amputation pain, and how do they relate to phantom limb pain?

Some procedures aim to reduce abnormal nerve signaling from the residual limb, especially when neuromas or nerve-end irritation are part of the picture. When residual limb pain is reduced, phantom limb pain can sometimes improve as well, although that is not guaranteed.²³⁶

Two surgical approaches that have gained attention are targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI). In a randomized clinical trial, TMR improved phantom limb pain compared with conventional neurectomy in major limb amputees.²⁰ Evidence for RPNI is growing, including reports of improved residual limb pain and some improvement in phantom phenomena, with phantom limb pain sometimes showing more modest change.²¹ These procedures are specialized, so it is reasonable to ask whether a center has specific experience, what outcomes they track, and whether the main target is neuroma pain, prosthetic tolerance, phantom limb pain, or all of the above.²⁰²¹

When is neuromodulation considered for phantom limb pain?

Neuromodulation means using stimulation to alter pain processing in nerves, the spinal cord, or the brain. For phantom limb pain, neuromodulation is typically discussed only when pain is chronic, disabling, and resistant to a well-documented course of conservative therapies, including rehabilitation approaches and medication trials.¹⁵¹⁶

A health technology assessment reviewing brain and spinal stimulation therapies for phantom limb pain concluded that the evidence has substantial uncertainty and does not clearly identify a best option, largely because studies are small and heterogeneous.¹⁵ A separate review of neuromodulation techniques in phantom limb pain similarly notes limited high-quality data for invasive neuromodulation approaches, and calls for more rigorous trials.¹⁶ This uncertainty matters: it does not mean neuromodulation never helps, it means decisions should be made carefully in specialized centers with clear expectations and a clear plan for follow-up.¹⁵¹⁶

What neuromodulation options may be discussed, from least invasive to most invasive?

Some options aim to change pain networks without implants, while others involve implanted hardware. Access and coverage vary by country and by health system, and some approaches are offered mainly in specialized centers.¹⁶¹⁷

Before listing, these options are grouped by how invasive they are, and by where stimulation is delivered:
 • Non-invasive brain stimulation, such as transcranial direct current stimulation (tDCS) or repetitive transcranial magnetic stimulation (rTMS): a review of neuromodulation in phantom limb pain reports randomized-trial evidence suggesting certain excitatory motor cortex stimulation protocols can reduce pain, though availability and protocols vary.¹⁶
 • Spinal or peripheral stimulation approaches: sometimes discussed for chronic phantom limb pain, but evidence remains uncertain and is often based on small studies.¹⁵¹⁶
 • Motor cortex stimulation (MCS): an implanted approach used in some refractory neuropathic pain syndromes, occasionally including phantom limb pain in broader chronic pain discussions.¹⁷
 • Deep brain stimulation (DBS): an implanted approach targeting deep brain pain circuits, generally reserved for severe, refractory chronic pain, with limited condition-specific data for phantom limb pain.¹⁵¹⁶¹⁷

If neuromodulation is being considered, it helps to ask which pain mechanism your team believes is dominant in your case, peripheral neuroma-driven signals, central sensitization, or mixed, and which modality best matches that hypothesis.¹⁶¹⁷

What is deep brain stimulation for pain, and what is known specifically about phantom limb pain?

Deep brain stimulation for pain involves implanting electrodes in specific brain targets that participate in pain signaling and pain modulation. Reviews describe targets such as sensory thalamic regions and brainstem-related targets like the periaqueductal or periventricular gray, and more recent exploration of targets linked to the emotional suffering component of pain.¹⁷

For phantom limb pain specifically, the evidence base for DBS is limited and not as mature as DBS for movement disorders. The best available syntheses emphasize uncertainty, small study sizes, and variable outcomes across chronic pain conditions.¹⁵¹⁶¹⁷ If DBS comes up, it usually means the team is weighing it as a last-line option after other therapies, including less invasive neuromodulation, have not provided acceptable relief.¹⁵¹⁷

What can I track to help my care team tailor treatment and avoid “trial-and-error fatigue”?

Tracking helps you and your clinicians see patterns that memory often blurs, especially when pain is frequent. It also helps document what has truly been tried, which matters if specialty referral or advanced therapies are being considered.²³¹⁵

Before listing, these bullets cover the most useful signals: pain pattern, triggers, residual limb factors, and function outcomes.
 • Phantom limb pain pattern: location in the missing limb, quality (burning, stabbing, cramping), duration, and flare timing.³⁷
 • Residual limb factors: skin irritation, socket pressure points, swelling, wound issues, suspected neuroma tenderness, and prosthesis tolerance time.²³
 • Triggers and modifiers: stress, sleep loss, temperature shifts, prosthesis use, and activity.³⁷
 • Functional impact: walking, transfers, sleep, mood, ability to use a prosthesis, and ability to participate in rehab.²³
 • Treatment trials: mirror therapy or graded motor imagery schedule, medication changes, therapy sessions, and what improved, pain intensity, frequency, sleep, function.¹⁸¹⁹¹⁰

What questions can I bring to my medical team if phantom limb pain is not improving?

When pain is persistent, the conversation can feel like it disappears behind a mask of complexity. A good question lifts the mask, one clear decision point at a time.

These questions are designed to support shared planning without pushing you toward any specific procedure:
 • Are my symptoms mainly phantom limb pain, residual limb pain, or both, and what findings support that?²³
 • Could a neuroma, infection, poor prosthetic fit, or skin breakdown be sustaining pain signals, and how do we evaluate that?²³
 • Which rehab-based therapies are most appropriate for me, mirror therapy, graded motor imagery, desensitization, and what is a realistic timeline to judge benefit?¹⁸¹⁹²³
 • What medication class do you recommend trying first for my risk profile, and what side effects should we watch closely?¹⁰¹¹
 • Should we discuss referral to an amputation pain specialist team for options like TMR or RPNI, and do I meet criteria?²⁰²¹
 • If neuromodulation is on the table, what is the least invasive option worth trying first, and what evidence supports it for phantom limb pain?¹⁵¹⁶

When should post-amputation pain be treated as an emergency?

Seek emergency care if pain comes with signs of serious infection or a medical emergency, such as high fever, rapidly spreading redness, pus or foul drainage from the residual limb, sudden severe swelling, new chest pain or shortness of breath, fainting, or new neurologic symptoms.²³³

If you feel overwhelmed to the point of thinking about self-harm, treat that as an urgent emergency as well, pain is heavy, and you deserve immediate support and safety.²
SAFETY NOTE
This page is educational and can’t diagnose or treat. If symptoms are urgent, sudden, or severe, or there are signs of infection, new neurologic symptoms, chest pain, shortness of breath, fainting, or you feel unsafe, seek emergency care right away.²³³

GLOSSARY
Amputation: Surgical or traumatic removal of a limb or part of a limb.
Central Sensitization: Increased sensitivity within the brain and spinal cord that can amplify pain signals over time.
Desensitization: A rehab approach that gently retrains the nervous system to tolerate touch and sensation without triggering high pain.
Deep Brain Stimulation (DBS): An implanted therapy that delivers electrical stimulation to specific brain targets to change activity in pain-related circuits.
Graded Motor Imagery: A structured therapy that uses left-right recognition, imagined movement, and often mirror therapy to retrain the brain’s body map.
Mirror Therapy: A visual technique that uses a mirror to make it look like the missing limb is present and moving normally.
Neuroma: A thickened, irritated end of a cut nerve that can produce abnormal pain signals.
Neuromodulation: Use of electrical stimulation to change nerve or brain signaling involved in pain.
Neuropathic Pain: Pain caused by disease or injury affecting the nervous system that carries sensation.
Phantom Limb Pain: Pain that feels like it comes from a limb, or part of a limb, that is no longer present after amputation.
Phantom Limb Sensations: Non-painful feelings that the missing limb is still present, such as tingling or movement.
Residual Limb Pain: Pain felt in the remaining part of the limb that is still physically present after amputation.
Regenerative Peripheral Nerve Interface (RPNI): A surgical method that places a cut nerve ending into a small muscle graft to reduce neuroma-related pain and improve nerve signaling.
Targeted Muscle Reinnervation (TMR): A surgical method that reroutes cut nerves into nearby muscles, originally developed to improve prosthetic control and also used to reduce post-amputation pain.

REFERENCES
1. International Association for the Study of Pain. Current understanding of phantom pain and its treatment. 2022. https://www.iasp-pain.org/current-understanding-of-phantom-pain-and-its-treatment/(https://www.iasp-pain.org/current-understanding-of-phantom-pain-and-its-treatment/?utm_source=chatgpt.com)
2. American Academy of Physical Medicine and Rehabilitation. Phantom Pain. Updated 2023. https://now.aapmr.org/phantom-pain/(https://now.aapmr.org/phantom-pain/?utm_source=chatgpt.com)
3. Hanyu-Deutmeyer AA, Cascella M, Varacallo M. Phantom Limb Pain. StatPearls. Updated 2023. https://www.ncbi.nlm.nih.gov/books/NBK448188/(https://www.ncbi.nlm.nih.gov/books/NBK448188/?utm_source=chatgpt.com)
4. Schug SA, Lavand’homme P, Barke A, Korwisi B, Rief W, Treede RD. The IASP classification of chronic pain for ICD-11: chronic neuropathic pain. Pain. 2019;160(1):53-59. https://anaesthetics.ukzn.ac.za/wp-content/uploads/2022/11/SCHUG-S.The_IASP_classification_of_chronic_pain_for.6.pdf(https://anaesthetics.ukzn.ac.za/wp-content/uploads/2022/11/SCHUG-S.The_IASP_classification_of_chronic_pain_for.6.pdf?utm_source=chatgpt.com)
5. Limakatso K, Parker R, Madden VJ, et al. The prevalence of phantom limb pain in people with amputations: a systematic review and meta-analysis. PLoS One. 2020;15(10):e0240431. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240431()
6. Limakatso K, Madden VJ, Parker R. The prevalence and risk factors for phantom limb pain. 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC10845739/(https://pmc.ncbi.nlm.nih.gov/articles/PMC10845739/?utm_source=chatgpt.com)
7. Subedi B, Grossberg GT. Phantom limb pain: mechanisms and treatment approaches. Pain Res Treat. 2011;2011:864605. https://pmc.ncbi.nlm.nih.gov/articles/PMC3198614/(https://pmc.ncbi.nlm.nih.gov/articles/PMC3198614/?utm_source=chatgpt.com)
8. Limakatso K, Cashin AG, Williams S, Devonshire J, Parker R. The efficacy of graded motor imagery and its components on phantom limb pain and disability: a systematic review and meta-analysis. Can J Pain. 2023. https://pubmed.ncbi.nlm.nih.gov/37214633/(https://pubmed.ncbi.nlm.nih.gov/37214633/?utm_source=chatgpt.com)
9. Xie HM, Zhang Q, Chen G, et al. Effectiveness of mirror therapy for phantom limb pain: a systematic review and meta-analysis. Ann Vasc Surg. 2022. https://www.sciencedirect.com/science/article/abs/pii/S0003999321013794(https://www.sciencedirect.com/science/article/abs/pii/S0003999321013794?utm_source=chatgpt.com)
10. Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015;14(2):162-173. https://pmc.ncbi.nlm.nih.gov/articles/PMC4493167/(https://pmc.ncbi.nlm.nih.gov/articles/PMC4493167/?utm_source=chatgpt.com)
11. National Institute for Health and Care Excellence. Neuropathic pain in adults: pharmacological management in non-specialist settings (CG173). https://www.nice.org.uk/guidance/cg173/chapter/1-recommendations(https://www.nice.org.uk/guidance/cg173/chapter/1-recommendations?utm_source=chatgpt.com)
12. International Association for the Study of Pain. Relief: A new treatment for phantom limb pain. 2026. https://www.iasp-pain.org/publications/relief-news/article/a-new-treatment-for-phantom-limb-pain/(https://www.iasp-pain.org/publications/relief-news/article/a-new-treatment-for-phantom-limb-pain/?utm_source=chatgpt.com)
13. Dumanian GA, Potter BK, Mioton LM, et al. Targeted muscle reinnervation treats neuroma and phantom pain in major limb amputees: a randomized clinical trial. Ann Surg. 2019;270(2):238-246. https://pubmed.ncbi.nlm.nih.gov/30371518/(https://pubmed.ncbi.nlm.nih.gov/30371518/?utm_source=chatgpt.com)
14. Corbett M, South E, Harden M, et al. Brain and spinal stimulation therapies for phantom limb pain. NIHR Health Technology Assessment. 2018. https://www.ncbi.nlm.nih.gov/books/NBK532712/(https://www.ncbi.nlm.nih.gov/books/NBK532712/?utm_source=chatgpt.com)
15. Pacheco-Barrios K, Meng F, Florencio LL, et al. Neuromodulation techniques in phantom limb pain: a systematic review. Neuromodulation. 2020. https://pmc.ncbi.nlm.nih.gov/articles/PMC7593798/(https://pmc.ncbi.nlm.nih.gov/articles/PMC7593798/?utm_source=chatgpt.com)
16. Knotkova H, Hamani C, Sivanesan E, et al. Neuromodulation for chronic pain. Lancet. 2021;397(10289):2111-2124. https://pubmed.ncbi.nlm.nih.gov/34062145/(https://pubmed.ncbi.nlm.nih.gov/34062145/?utm_source=chatgpt.com)
17. Farrell SM, Green AL, Aziz TZ. The current state of deep brain stimulation for chronic pain and its clinical applications. Brain Sci. 2018;8(8):158. https://www.mdpi.com/2076-3425/8/8/158(https://www.mdpi.com/2076-3425/8/8/158?utm_source=chatgpt.com)
18. Lee JC, et al. Regenerative peripheral nerve interface surgery to treat post-amputation pain. 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC11932616/(https://pmc.ncbi.nlm.nih.gov/articles/PMC11932616/?utm_source=chatgpt.com)

ChatGPT can make

Question 4

CANCER RELATED PAIN

Accepted Answer

What is cancer-related pain?

Cancer-related pain is pain caused by the cancer itself, cancer treatments, or complications that happen along the way, like infections, fractures, or nerve injury.³⁵ It can show up as a steady ache, sharp spikes, burning nerve pain, pressure, cramping, or a mix that changes over time.³⁵

One important idea is that cancer pain is often “multi-factor.” A person can have bone pain from metastases, nerve pain from tumor pressure, and muscle pain from guarding, all at once.³⁵ This is why treatment plans usually combine approaches rather than relying on a single medication or a single procedure.³⁵

How common is cancer-related pain?

Cancer-related pain is common, but how common depends on where someone is in their cancer journey. A large meta-analysis found pain prevalence around 39% after curative treatment, 55% during anticancer treatment, and 66% in advanced, metastatic, or terminal disease.¹

More recent work suggests prevalence and severity may be declining compared with older decades, likely related to better awareness and more consistent pain assessment and supportive care, but pain is still a major burden for many people.² That mix of “common, changing over time” is why routine screening and repeat check-ins are built into major guidelines.³⁶

What are the main types of cancer-related pain?

Clinicians often describe cancer pain by mechanism because the mechanism points to different tools. The big categories are nociceptive pain, meaning pain from tissue injury or inflammation (like bone or organ pain), and neuropathic pain, meaning pain from nerve injury or nerve compression (often burning, tingling, electric, or touch-sensitive).³⁵

Many people have mixed pain, where both mechanisms are happening at the same time.³⁵ This matters because neuropathic pain often needs “adjuvant” medicines or targeted procedures in addition to opioids or anti-inflammatory medicines.³⁵

What is the difference between background pain and breakthrough cancer pain?

Background pain is the “baseline” level of pain that tends to be present most of the day.³⁵ Breakthrough cancer pain is a sudden flare on top of that baseline, often reaching peak intensity quickly and lasting minutes to hours.⁵

Breakthrough pain can be predictable, like pain that spikes during movement or dressing changes, or unpredictable.⁵ Major guidelines emphasize treating both layers, a stable plan for baseline pain, plus a clear plan for flares.³⁵

Why can cancer-related pain change so quickly?

Cancer pain can change quickly because the underlying drivers can change quickly. Tumors can irritate nerves, stretch organ capsules, inflame tissue, or weaken bone, and treatment can cause new pain patterns like nerve injury or mucositis.³⁵

Pain can also change because the body’s sensitivity changes. Poor sleep, anxiety, dehydration, infection, and medication side effects can amplify pain perception, even if the cancer itself hasn’t changed.³⁶ This is why good pain care includes symptom management beyond pain alone, like sleep, nausea, constipation, and mood strain.³⁶

How is cancer-related pain assessed in clinic?

Most guidelines start with a simple truth: pain has to be asked about, early and often.³⁶ Clinicians typically assess location, intensity, quality, timing, triggers, what improves it, and how it affects function like walking, eating, and sleeping.³⁶

A strong assessment also asks about the “why.” Is the pain likely from bone metastases, nerve compression, inflammation, treatment side effects, constipation, or something urgent like infection or spinal cord compression?³⁶ When the “why” is clearer, the plan gets less random and more targeted.³⁶

What red flags mean cancer pain needs urgent evaluation?

Some pain patterns suggest a time-sensitive problem. New severe back pain with weakness, numbness, or bowel or bladder changes can be a red flag for spinal cord compression and needs urgent evaluation.³⁶ New severe headache with neurologic changes, severe chest pain, shortness of breath, fever with shaking chills, or rapidly worsening swelling also deserves urgent care.³⁶

If pain suddenly changes character, becomes rapidly worse, or is paired with new confusion, fainting, uncontrolled vomiting, or new inability to take fluids, it is reasonable to treat that as urgent.³⁶ Cancer pain is common, but emergencies can hide inside “just pain,” and fast evaluation protects safety.³⁶

What are the core building blocks of cancer pain treatment plans?

Most evidence-based plans are layered. They combine treatment of the cause when possible, such as radiation for painful bone metastases, with symptom control, such as analgesics, constipation prevention, and nausea control.³⁸

Another core piece is matching the plan to goals and daily life. Guidelines emphasize function, sleep, and quality of life as real outcomes, not just a pain number.³⁶ If the plan reduces pain but leaves someone too sedated to live their day, the plan still needs refinement.³⁶

How does the WHO approach to cancer pain medicines work today?

The World Health Organization (WHO) has long described a stepwise approach to cancer pain medicines, often taught as the “analgesic ladder.”⁴ The core message is still widely used: start with the least intensive option likely to help, then step up in a structured way, adding adjuvant medicines and non-drug supports as needed.⁴⁵

WHO guidance has also evolved over time, including updates that reflect real-world use, such as flexibility around the classic “step 2” concept in some situations.⁷ This matters because cancer pain isn’t always polite or gradual, sometimes it needs faster escalation, and the safest plan is often the one that is structured, monitored, and adjusted quickly.⁴⁷

When are non-opioid medicines used for cancer-related pain?

Non-opioid medicines can be used alone for mild pain or combined with opioids for moderate to severe pain, depending on the person and the pain driver.⁴⁵ For example, anti-inflammatory medicines may help when inflammation is a major contributor, and acetaminophen may be used as part of combination therapy when appropriate.⁴⁵

Guidelines also emphasize balancing benefit with risk, especially in people with kidney disease, bleeding risk, or fragile stomach lining.⁵ If a clinician recommends avoiding a certain non-opioid medicine, it is usually about protecting safety, not withholding relief.⁵

When are opioids used, and what safety steps are standard in cancer care?

ASCO guidance recommends offering opioids for moderate to severe pain related to cancer or active cancer treatment unless contraindicated.⁶ This is not a “last resort” when used correctly, it is one of the standard tools for serious cancer pain when the situation calls for it.⁶

Safety is part of the same plan, not an afterthought. Major guidelines emphasize regular reassessment, side effect prevention, careful dose titration, and attention to risks like sedation, falls, and interactions with other medicines.³⁶ ASCO also emphasizes evaluating risks and benefits, and adjusting the plan based on response and side effects, especially as disease status and treatments change.⁶

How is opioid-induced constipation prevented and treated?

Opioids commonly slow gut movement, and constipation can become a major source of suffering if it is not addressed early.³ NCCN guidance recommends starting constipation prophylaxis when opioids are initiated, commonly with a stimulant laxative, sometimes combined with a stool softener depending on the situation.³

This prevention step matters because constipation can worsen pain, appetite, nausea, and sleep, and it can lead to urgent visits when severe.³⁶ If constipation becomes persistent despite first-line measures, clinicians may consider additional strategies, including peripherally acting mu-opioid receptor antagonists in appropriate patients, and this decision should be individualized to medical history and overall plan.³

What are “adjuvant analgesics,” and when are they used?

Adjuvant analgesics are medicines that are not primarily “painkillers” but can reduce pain by targeting specific mechanisms, especially nerve pain or bone-related pain.⁴⁵ Common categories include certain antidepressants and anticonvulsants for neuropathic pain, and corticosteroids in specific scenarios when inflammation or nerve compression is contributing.⁴⁵

In cancer care, adjuvants are often used alongside opioids, not instead of them, when the pain has a neuropathic component or when opioid side effects limit dose escalation.³⁵ The goal is often “less pain with fewer side effects,” not simply “more medication.”³⁵

How is chemotherapy-induced peripheral neuropathy pain treated?

Chemotherapy-induced peripheral neuropathy (CIPN) can cause numbness, tingling, and painful burning or shooting sensations, often in hands and feet.⁹ It can affect balance, sleep, and the ability to tolerate ongoing therapy.⁹

ASCO’s guideline update states that duloxetine is recommended for treatment of painful CIPN based on evidence, while many other proposed options have insufficient or inconsistent evidence.⁹ That doesn’t mean other approaches are never used, it means the strongest guideline-backed medication option for painful CIPN is duloxetine, and any additional options are typically discussed as individualized, evidence-limited choices.⁹

How can radiation therapy help cancer-related pain?

Radiation therapy can be an effective way to relieve pain when the pain source is localized and treatable, especially painful bone metastases.⁸ It can reduce tumor burden in the targeted area and lower pain over time.⁸

ASTRO guidance supports several effective dose schedules for uncomplicated painful bone metastases, including single-fraction and multi-fraction regimens, with regimen choice often balancing convenience, retreatment risk, and the person’s overall situation.⁸ This is a “treat the cause” strategy, often paired with medicines while radiation takes effect.⁸

What interventional pain procedures are used for cancer-related pain?

Interventional procedures aim to interrupt or reduce pain signals more directly, especially when medication side effects are limiting or when pain is coming from a specific nerve pathway.³⁵ These can include nerve blocks, neurolytic blocks, vertebral procedures in selected bone pain scenarios, and other region-specific interventions depending on anatomy and diagnosis.³⁵

For example, celiac plexus neurolysis has evidence for reducing abdominal pain in unresectable pancreatic cancer, with meta-analytic data supporting efficacy, though duration and individual response vary.¹⁰ These interventions are typically considered with pain or palliative specialists who can weigh benefits, risks, and realistic expectations.¹⁰

When is intrathecal drug delivery considered for cancer-related pain?

Intrathecal drug delivery means delivering pain medicine into the fluid around the spinal cord through an implanted pump, allowing lower systemic doses in some cases.¹¹ It is generally considered when pain is severe and refractory, side effects from systemic opioids are limiting, or when pain has a pattern that may respond well to neuraxial therapy.¹¹

The Polyanalgesic Consensus Conference (PACC) provides evidence- and consensus-based best-practice guidance for intrathecal drug delivery in cancer pain, emphasizing patient selection, safety, and therapy optimization.¹¹ These are complex decisions, usually made in specialty settings with clear follow-up plans.¹¹

What non-drug and supportive therapies can strengthen a cancer pain plan?
Non-drug supports are not “extra,” they often make the medical plan work better. NCCN guidance highlights nonpharmacologic and integrative strategies as part of comprehensive cancer pain care, including movement and rehab support, relaxation strategies, and coordinated symptom management.³⁶

Another major piece is palliative care. ASCO recommends early palliative care involvement, especially for people with uncontrolled symptoms and quality of life concerns, and pain is one of the most common reasons this support helps.¹² Palliative care can work alongside oncology, focusing on relief, coping support, and aligning treatment with goals.¹²

How can cancer pain be managed when someone has a history of substance use disorder or higher risk with opioids?

This situation deserves care that is both compassionate and structured. ASCO’s opioid guideline includes guidance on balancing effective relief with risk mitigation, including careful assessment, monitoring, and using the lowest intensity plan that still meets pain control goals.⁶

It can also include shared agreements about how medicines are prescribed, closer follow-up, involving palliative care or pain specialists, and prioritizing non-opioid and interventional options when appropriate.³⁶ The aim is not punishment, it is safety plus relief, both at the same time.⁶³⁶

What neuromodulation options exist for cancer-related pain, and where does DBS fit?

Neuromodulation means using electrical stimulation to change how pain signals are processed in the nervous system. It spans non-invasive approaches, spinal and peripheral stimulation, and in rare, highly selected situations, deep brain stimulation (DBS).¹³

DBS for pain targets deep brain circuits involved in pain perception and modulation, including regions such as sensory thalamus and periaqueductal or periventricular gray, and sometimes affective targets like anterior cingulate pathways in research settings.¹³¹⁴ For cancer-related pain specifically, DBS is not a standard pathway, and the evidence base is far smaller and more variable than DBS for movement disorders.¹³¹⁴ If DBS is discussed, it usually signals an advanced, refractory situation being evaluated in a specialized center, often after other medical, radiation, and interventional strategies have been exhausted.¹³¹⁴

What questions can I bring to my oncology or palliative care visit?
Good questions can pull the plan into the light, especially when pain has been wearing a mask of complexity. The goal is clarity about cause, a stepwise plan, and what “success” looks like for you.

these questions are designed to support shared decision-making without pushing you toward any single treatment:
 • What do you think is driving my pain right now, bone, nerve compression, inflammation, treatment side effect, constipation, or something else?³⁶
 • Is there a “treat the cause” option like radiation for a painful site, and what timeline should I expect for relief?⁸
 • What is our plan for baseline pain and for breakthrough flares, and how will we measure whether the plan is working?³⁵
 • If opioids are needed, what is the constipation prevention plan from day one, and what should I do if it starts?³
 • If nerve pain is part of this, which adjuvant options fit my situation, and what side effects should we watch?⁴⁵
 • If pain remains uncontrolled, should we discuss a nerve block, neurolysis, or intrathecal therapy referral, and what evidence supports that for my cancer type and pain site?¹⁰¹¹
 • Would early palliative care involvement help coordinate symptom relief and support my daily function and goals?¹²

How do availability and care pathways differ by country?

Across countries, the broad principles of cancer pain care are similar, assess often, treat the cause when possible, use stepwise analgesic plans, and prevent side effects.⁴⁵

What differs most is access: medication availability, opioid regulations, coverage for interventional procedures, and how easily someone can reach palliative care or pain specialists. WHO guidance was designed in part to support safe, equitable access to effective cancer pain medicines globally, but real-world access still varies.⁴
SAFETY NOTE
This page is educational and can’t diagnose or treat. If symptoms are urgent, sudden, or severe, or pain is paired with new weakness, numbness, confusion, fever, chest pain, shortness of breath, or rapidly worsening swelling, seek emergency care right away.³⁶

GLOSSARY
Adjuvant Analgesic: A medication not primarily labeled as a pain medicine that can reduce pain by targeting specific mechanisms, often nerve pain or inflammation.
Analgesic Ladder: A stepwise framework for selecting pain medicines, commonly associated with WHO cancer pain guidance.
Breakthrough Cancer Pain: A temporary flare of pain that “breaks through” baseline control, often starting quickly and lasting minutes to hours.
Celiac Plexus Neurolysis: A procedure that disrupts pain signaling from abdominal organs by targeting the celiac plexus nerves, sometimes used for pancreatic cancer pain.
Chemotherapy-Induced Peripheral Neuropathy: Nerve damage from chemotherapy that can cause numbness, tingling, and sometimes painful burning or shooting sensations.
Intrathecal Drug Delivery: Delivery of pain medicine into the fluid around the spinal cord via an implanted pump and catheter.
Neuropathic Pain: Pain caused by nerve injury or nerve dysfunction, often described as burning, electric, tingling, or touch-sensitive.
Neuromodulation: Use of electrical stimulation to change nerve or brain signaling involved in pain.
Nociceptive Pain: Pain from tissue injury or inflammation, often described as aching, throbbing, or pressure-like.
Opioid-Induced Constipation: Constipation caused by opioids slowing the gut, often requiring preventive treatment from the start.
Palliative Care: Specialized care focused on symptom relief, quality of life, and support for people living with serious illness, alongside disease-directed treatment.
Residual Pain Driver: A treatable condition that continues to generate pain signals, such as constipation, infection, fracture risk, or nerve compression.
Spinal Cord Compression: Pressure on the spinal cord that can cause severe back pain and neurologic changes, considered an emergency.

REFERENCES
1. van den Beuken-van Everdingen MHJ, Hochstenbach LMJ, Joosten EAJ, Tjan-Heijnen VCG, Janssen DJA. Update on prevalence of pain in patients with cancer: systematic review and meta-analysis. J Pain Symptom Manage. 2016;51(6):1070-1090.e9. https://www.jpsmjournal.com/article/S0885-3924(16)30048-3/fulltext()
2. Snijders RAH, Brom L, Theunissen M, et al. Update on prevalence of pain in patients with cancer 2022: systematic review and meta-analysis. Cancers (Basel). 2023;15(3):591. https://www.mdpi.com/2072-6694/15/3/591(https://www.mdpi.com/2072-6694/15/3/591?utm_source=chatgpt.com)
3. Swarm RA, Paice JA, Anghelescu DL, et al. Adult Cancer Pain, Version 2.2025, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2025;23(7):e250032. https://jnccn.org/view/journals/jnccn/23/7/article-e250032.xml?print=(https://jnccn.org/view/journals/jnccn/23/7/article-e250032.xml?print&utm_source=chatgpt.com)
4. World Health Organization. WHO guidelines for the pharmacological and radiotherapeutic management of cancer pain in adults and adolescents. 2019. https://www.who.int/publications/i/item/9789241550390(https://www.who.int/publications/i/item/9789241550390?utm_source=chatgpt.com)
5. Fallon M, Giusti R, Aielli F, et al. Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Ann Oncol. 2018;29(suppl_4):iv166-iv191. https://www.annalsofoncology.org/article/S0923-7534(19)31698-9/fulltext()
6. Paice JA, Portenoy R, Lacchetti C, et al. Use of opioids for adults with pain from cancer or cancer treatment: ASCO guideline. J Clin Oncol. 2023;41(4):914-930. https://ascopubs.org/doi/10.1200/JCO.22.02198(https://ascopubs.org/doi/10.1200/JCO.22.02198?utm_source=chatgpt.com)
7. Bramati PS, Celli BR, Ripamonti CI. The end of the second step of the World Health Organization analgesic ladder? Ann Oncol. 2022;33(6):557-559. https://www.annalsofoncology.org/article/S0923-7534(22)03966-7/fulltext()
8. American Society for Radiation Oncology. Bone Metastases Guideline. 2023. https://www.astro.org/ASTRO/media/ASTRO/Patient%20Care%20and%20Research/PDFs/BoneMets_PC.pdf(https://www.astro.org/ASTRO/media/ASTRO/Patient%20Care%20and%20Research/PDFs/BoneMets_PC.pdf?utm_source=chatgpt.com)
9. Loprinzi CL, Lacchetti C, Bleeker J, et al. Prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers: ASCO guideline update. J Clin Oncol. 2020;38(28):3325-3348. https://ascopubs.org/doi/10.1200/JCO.20.01399(https://ascopubs.org/doi/10.1200/JCO.20.01399?utm_source=chatgpt.com)
10. Okita M, Otani K, Gibo N, et al. Systematic review and meta-analysis of celiac plexus neurolysis for abdominal pain associated with unresectable pancreatic cancer. Pain Pract. 2022;22(6):652-661. https://pubmed.ncbi.nlm.nih.gov/35748531/(https://pubmed.ncbi.nlm.nih.gov/35748531/?utm_source=chatgpt.com)
11. Deer TR, Hayek SM, Grider JS, et al. The Polyanalgesic Consensus Conference (PACC)®: Updates on clinical pharmacology and comorbidity management in intrathecal drug delivery for cancer pain. Neuromodulation. 2025;28(7):1029-1053. https://pubmed.ncbi.nlm.nih.gov/39297833/(https://pubmed.ncbi.nlm.nih.gov/39297833/?utm_source=chatgpt.com)
12. Sanders JJ, Temel JS, et al. Palliative care for patients with cancer: ASCO guideline update. J Clin Oncol. 2024. https://ascopubs.org/doi/10.1200/JCO.24.00542(https://ascopubs.org/doi/10.1200/JCO.24.00542?utm_source=chatgpt.com)
13. Bouali-Benazzouz R, et al. Targeting pain with deep brain stimulation: insights into the thalamus and associated structures. DBS J. 2025. https://www.sciencedirect.com/science/article/pii/S2949669125000120(https://www.sciencedirect.com/science/article/pii/S2949669125000120?utm_source=chatgpt.com)
14. Al-Husinat LI, et al. Deep brain stimulation for chronic pain: mechanisms, clinical applications, limitations, and future directions. Front Med. 2025. https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2025.1683991/full(https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2025.1683991/full?utm_source=chatgpt.com)
15. The University of Texas MD Anderson Cancer Center. Cancer Pain, Adult: Clinical Management Algorithm. 2025. https://www.mdanderson.org/documents/for-physicians/algorithms/clinical-management/clin-management-cancer-pain-web-algorithm.pdf(https://www.mdanderson.org/documents/for-physicians/algorithms/clinical-management/clin-management-cancer-pain-web-algorithm.pdf?utm_source=chatgpt.com)

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Question 5

CENTRAL POST-STROKE PAIN

Accepted Answer

What is central post-stroke pain?

Central post-stroke pain (CPSP) is chronic neuropathic pain caused by a stroke injury to the brain pathways that process sensation. Neuropathic pain means pain caused by a lesion or disease of the somatosensory nervous system, the system that carries touch, temperature, and pain signals.¹²

CPSP is “central” because the injury is in the brain, not in the skin, muscle, or joint where the pain is felt.² It often affects the same side of the body impacted by the stroke and can involve the face, arm, leg, or a combination, depending on which sensory pathways were injured.²³

How common is central post-stroke pain?

Estimates vary because studies use different definitions and time windows, but CPSP is consistently described as a meaningful complication for a subset of stroke survivors.²⁴ A recent systematic review and meta-analysis described CPSP prevalence commonly reported in the range of roughly 8% to 35% across studies, highlighting wide variability.⁴

Even with that range, a practical takeaway is consistent across reviews: CPSP is common enough that persistent post-stroke pain deserves a structured evaluation for central neuropathic features, not only musculoskeletal causes.³⁴

When does CPSP usually start?

CPSP often develops weeks to months after a stroke, and it can emerge gradually rather than all at once.²³ Some people notice sensory changes first, like numbness, cold feeling “wrong,” or touch becoming unpleasant, and later the pain becomes more prominent.²³

CPSP can also begin earlier, especially when the stroke directly affects major sensory pathways.² The key is not the exact day it started, it is whether the pain pattern matches stroke-affected sensory territories and is paired with sensory abnormalities typical of neuropathic pain.²³

What does central post-stroke pain feel like?

CPSP is commonly described as burning, freezing, aching, stabbing, squeezing, or electric pain.²³ It may be continuous, intermittent, or layered, for example a steady background burn with spikes triggered by touch, temperature changes, or movement.²³

Many people also describe mixed sensations in the same area, such as numbness plus pain, or tingling plus a deep ache. This “mixed signal” experience fits what is seen when sensory pathways are damaged and the brain’s processing of incoming input becomes distorted.³⁴

What are allodynia and hyperalgesia, and why do they matter in CPSP?

Allodynia means pain caused by something that normally shouldn’t hurt, like light touch, clothing, or a gentle breeze. Hyperalgesia means an exaggerated response to something that normally is painful.¹²³

These features matter because they point to a neuropathic mechanism rather than purely mechanical or inflammatory pain. Reviews of CPSP repeatedly highlight sensory abnormalities, including touch-evoked pain and temperature sensitivity, as core clues that the stroke altered central sensory processing.³⁴

How is CPSP different from other post-stroke pain problems?

After stroke, pain can come from several sources. Common non-central causes include hemiplegic shoulder pain, spasticity-related pain, joint stiffness, soft tissue injury, and overuse from compensation patterns.⁵ These often respond to positioning, range-of-motion plans, spasticity management, and targeted rehabilitation strategies.⁵

CPSP is different because it is driven by a lesion in central sensory pathways. Clinically, CPSP is more likely when pain is paired with abnormal sensation on exam and when touch or temperature triggers pain in a way that does not match a single joint or muscle pattern.²³⁴ Mixed pain is also common, meaning a person can have both shoulder pain and CPSP, and the plan may need separate tools for each driver.³⁵

What causes CPSP in the brain and nervous system?

CPSP is linked to stroke injury affecting the somatosensory system, including pathways that carry temperature and pain signals, and the brain regions that interpret them.³⁴ When these pathways are disrupted, the nervous system can develop abnormal excitability and altered inhibitory control, which can amplify signals or generate pain from inputs that previously felt neutral.³⁴

Modern models describe CPSP as involving both loss of normal sensory signaling and “gain” of abnormal pain signaling. This helps explain why an area can feel less sensitive to touch yet more sensitive to pain, and why the pain can persist even after the stroke is medically stable.³⁴

Which stroke locations are commonly linked to CPSP?

CPSP can follow strokes that involve the thalamus, brainstem, or cortical and subcortical regions that connect to sensory processing pathways.²³ The older term “thalamic pain syndrome” reflects classic recognition of thalamic involvement, but CPSP is not limited to thalamic lesions.²³

Across studies and reviews, the consistent theme is pathway relevance: CPSP is more plausible when the stroke affected structures or tracts involved in processing pain and temperature, such as spinothalamic-related pathways and thalamocortical sensory connections.²³⁴

How is central post-stroke pain diagnosed?

CPSP is diagnosed clinically using a careful history and a sensory-focused neurologic exam. Clinicians look for pain in a body region that corresponds to the stroke lesion plus sensory abnormalities such as impaired temperature sensation, altered pinprick, numbness, tingling, or touch-evoked pain.²³

Diagnosis also involves ruling out or separating other contributors. That means checking for shoulder subluxation, spasticity, joint inflammation, swelling, skin injury, headache syndromes, and complex regional pain syndrome when the pattern suggests it.⁵³ A good evaluation does not treat everything as CPSP, and it does not dismiss CPSP as “just rehab soreness.”³⁵

What tests or imaging are used in CPSP evaluation?

Most people already have brain imaging from the stroke workup, and clinicians often revisit those images to see whether sensory pathways were affected and whether the pain distribution fits the lesion.²³

Additional testing is individualized. Many cases can be diagnosed without specialized tests when the symptom pattern and exam are consistent.² In more complex cases, the workup often focuses on clarifying mixed mechanisms and identifying treatable non-central drivers that are increasing overall pain load.³⁵

What treatments are typically tried first for CPSP?

Most treatment plans start with evidence-supported neuropathic pain medications and a rehabilitation approach that reduces triggers while protecting function. Reviews and meta-analyses consistently identify antidepressants such as amitriptyline and SNRIs such as duloxetine, and anticonvulsants such as lamotrigine, as among the better-supported medication options for CPSP, with varying levels of evidence across drugs.³⁴⁶

A useful way to think about first-line care is “stepwise and measurable.” Clinicians typically introduce one main change at a time, set a clear trial window, and track outcomes like pain intensity, sleep, daily function, and side effects before deciding whether to continue, adjust, or switch.³⁴

How does amitriptyline fit into CPSP treatment?

Amitriptyline is frequently cited in CPSP literature as a treatment with randomized trial support. A controlled trial found amitriptyline reduced CPSP pain compared with placebo, while carbamazepine did not show the same benefit in that study.⁷

In evidence syntheses, amitriptyline remains a commonly recommended option, although side effects such as dry mouth, constipation, sedation, and dizziness can limit use for some people.³⁴ Because stroke survivors may have fall risk or medical comorbidities, clinicians typically individualize dosing and monitoring rather than using a one-size-fits-all approach.³⁵⁷

What do we know about duloxetine for CPSP?

Duloxetine has randomized, double-blind, placebo-controlled trial evidence in CPSP. In a trial of people with CPSP, duloxetine produced greater improvement in pain measures compared with placebo.⁸

Recent meta-analytic work also highlights duloxetine as one of the treatments with comparatively robust evidence among studied CPSP interventions.⁴ In clinical practice discussions, duloxetine may be considered especially when pain is tangled with sleep disruption or mood symptoms, while still weighing side effects and drug interactions.⁴⁸

What role does lamotrigine play, and what about other anticonvulsants?

Lamotrigine has randomized controlled trial evidence supporting benefit in CPSP, and it is repeatedly cited in CPSP reviews as an evidence-supported option.⁹³

Other anticonvulsants have been studied with mixed results. A systematic review and meta-analysis of CPSP pharmacotherapies reported signal for several drugs, while emphasizing that evidence quality varies and some findings are supported by small numbers of studies.⁶ A network meta-analysis also compared antidepressants and anticonvulsants, reflecting that multiple options may help some people, but comparative certainty remains limited.¹⁰ This is why clinicians often frame these trials as structured experiments with clear stop or switch points.⁶¹⁰

Are opioids used for CPSP?

Opioids are not typically considered first-line for central neuropathic pain after stroke in most CPSP-focused reviews because neuropathic pain often responds incompletely and because long-term opioid risks can be substantial.³⁶

That said, real-world care can involve short-term opioid use in selected situations, especially when pain is severe and other causes are present, but decisions should be individualized and closely monitored by the treating team.³⁵ The key is that CPSP usually requires neuropathic-targeted strategies rather than relying on opioids alone.³⁶

What non-drug approaches support CPSP treatment?

Non-drug approaches aim to reduce triggers and protect function while the nervous system stabilizes. Stroke rehabilitation guidance emphasizes addressing common post-stroke pain contributors such as shoulder mechanics, positioning, spasticity, and mobility limitations, which can reduce overall pain load even when CPSP is present.⁵

CPSP reviews also emphasize multimodal care because pain is influenced by sleep, stress physiology, activity patterns, and coexisting symptoms.³⁵ Non-drug supports can include pacing, graded activity plans, sleep-focused interventions, and psychological strategies that reduce distress and improve coping, not because the pain is imagined, but because pain processing is biologically sensitive to these factors.³⁵

What is rTMS, and how strong is the evidence for CPSP?

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive neuromodulation treatment that uses magnetic pulses to influence brain activity, often targeting motor cortex regions in neuropathic pain protocols.¹¹

A systematic review and meta-analysis reported that rTMS may reduce pain in CPSP, with ongoing uncertainty about optimal protocols, durability, and which patients respond best.¹¹ A separate systematic review and meta-analysis of CPSP interventions also identified rTMS among the treatments with comparatively stronger evidence in the current literature.⁴ If rTMS is being considered, it is reasonable to ask about session number, expected time course, how response is measured, and what the plan is if benefits fade.⁴¹¹

When are invasive neuromodulation options considered for CPSP?

Invasive neuromodulation is usually considered only when CPSP is severe, persistent, and disabling despite well-documented trials of medication and noninvasive strategies.³⁴ These decisions are typically made in specialized centers because selection, surgical planning, and long-term programming follow-up affect outcomes.³⁵

Options discussed in the CPSP literature include spinal cord stimulation (SCS), motor cortex stimulation (MCS), and deep brain stimulation (DBS). Reviews emphasize that evidence is limited and heterogeneous, and that more rigorous trials are needed, so expectations must be realistic and individualized.⁴³⁵

Where does deep brain stimulation fit for central post-stroke pain?

DBS for chronic pain involves implanting electrodes in deep brain targets involved in pain signaling and modulation, including sensory thalamic regions and brainstem-adjacent targets such as periaqueductal or periventricular gray, among others described in chronic pain DBS literature.¹²

For CPSP specifically, DBS is not a standard pathway and is generally considered only in highly selected, treatment-refractory cases. Evidence syntheses highlight variable outcomes and limited CPSP-specific data compared with more established indications of DBS in movement disorders.⁴¹² If DBS is discussed, it should include a careful review of goals, risks, center experience, and how success will be defined and measured over time.⁴¹²

What can I track to help my clinical team adjust treatment more effectively?

Tracking makes patterns visible. It helps clinicians separate central neuropathic triggers from musculoskeletal and spasticity-related contributors and helps document whether a treatment is improving not only pain but also sleep and function.³⁵

Before listing, these bullets focus on high-value data points that directly influence treatment choices:
 • Pain map: location, side, and whether it matches the stroke-affected region.²³
 • Sensory triggers: light touch, clothing, bathing, cool air, heat, and cold objects or water.²³
 • Pain quality and timing: burning, freezing, electric, aching, stabbing, steady baseline versus flares.²³
 • Function and sleep: therapy tolerance, walking, dressing, sleep disruption, fatigue, and mood strain.⁵³⁵
 • Coexisting pains: shoulder pain, spasticity pain, joint pain, swelling, skin breakdown, because mixed pain needs a mixed plan.⁵³⁵
 • Treatment response: what changed, how long benefit lasted, and side effects like sedation, dizziness, constipation, or nausea.³⁴

What questions can I bring to my next appointment?
These questions are meant to support shared planning and clear decision points, especially when pain is complex and persistent.

The goal of having questions is to clarify mechanism, choose a stepwise plan, and define how you’ll judge progress:
 • Does my pain pattern fit CPSP, mixed pain, or another post-stroke pain condition, and what exam findings support that?³⁵
 • What medication options have the best evidence for CPSP in my situation, and what side effects should we watch closely?⁴⁶⁷⁸⁹¹⁰
 • What is a fair trial length for a medication or rTMS course before we decide it helped, partially helped, or did not help?⁴⁶¹¹
 • What rehab strategies can reduce mechanical and spasticity-related pain contributors without reducing my activity too much?⁵
 • If pain remains severe, when would we discuss referral to a specialty center to evaluate neuromodulation options, and which option fits my risk profile?⁴¹²

When should post-stroke pain be treated as an emergency?

Seek emergency care if pain is paired with new stroke-like symptoms such as sudden weakness, facial droop, trouble speaking, vision changes, sudden severe confusion, fainting, or a sudden severe headache that is new for you.²

Also seek urgent care for high fever, rapidly spreading redness or swelling, chest pain, shortness of breath, or any sudden change that feels dangerous or out of character.²
SAFETY NOTE
This page is educational and can’t diagnose or treat. If symptoms are urgent, sudden, or severe, or pain comes with new neurologic symptoms, fever, chest pain, shortness of breath, fainting, or you feel unsafe, seek emergency care right away.

GLOSSARY
Allodynia: Pain from something that normally shouldn’t hurt, such as light touch or clothing.
Amitriptyline: A tricyclic antidepressant that can reduce neuropathic pain by changing pain-modulating signaling in the nervous system.
Central Nervous System: The brain and spinal cord.
Central Neuropathic Pain: Neuropathic pain caused by injury or disease within the brain or spinal cord.
Central Post-Stroke Pain (CPSP): Neuropathic pain caused by stroke injury to sensory pathways, usually in the same body region affected by the stroke.
Duloxetine: An SNRI antidepressant that is also used for some neuropathic pain conditions.
Hyperalgesia: Increased pain response to something that is normally painful.
Lamotrigine: An anticonvulsant medicine that can reduce neuropathic pain in some conditions, including CPSP in clinical trials.
Motor Cortex Stimulation (MCS): An implanted neuromodulation method that stimulates the motor cortex to reduce certain refractory neuropathic pain states.
Neuromodulation: Use of electrical stimulation to change nerve or brain signaling involved in pain.
Neuropathic Pain: Pain caused by a lesion or disease of the nervous system that carries sensation.
Repetitive Transcranial Magnetic Stimulation (rTMS): A noninvasive treatment that uses magnetic pulses to influence brain activity, sometimes used for neuropathic pain.
Somatosensory Nervous System: The nerve pathways that carry touch, temperature, and pain signals and help the brain interpret sensation.
Spinal Cord Stimulation (SCS): An implanted device that stimulates the spinal cord to reduce pain signaling in some chronic pain conditions.
Thalamic Pain Syndrome: An older term sometimes used for CPSP when the thalamus is involved, but CPSP can occur from other sensory pathway lesions too.

REFERENCES
1. International Association for the Study of Pain. IASP terminology: Neuropathic pain. https://www.iasp-pain.org/resources/terminology/(https://www.iasp-pain.org/resources/terminology/?utm_source=chatgpt.com)
2. Anosike KC, Cascella M. Central Poststroke Pain Syndrome. StatPearls. Updated 2024. https://www.ncbi.nlm.nih.gov/books/NBK604196/(https://www.ncbi.nlm.nih.gov/books/NBK604196/?utm_source=chatgpt.com)
3. Mulla SM, Wang L, Khokhar R, et al. Management of central poststroke pain: systematic review of randomized controlled trials and meta-analyses. Stroke. 2015;46(10):2852-2860. https://www.ahajournals.org/doi/10.1161/STROKEAHA.115.010259()
4. Tamasauskas A, Iwanaga J, Tubbs RS, et al. Management of central poststroke pain: systematic review and meta-analysis. J Pain. 2025;26(2):149-170. https://www.sciencedirect.com/science/article/pii/S1526590024006229(https://www.sciencedirect.com/science/article/pii/S1526590024006229?utm_source=chatgpt.com)
5. Winstein CJ, Stein J, Arena R, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016;47(6):e98-e169. https://www.ahajournals.org/doi/10.1161/STR.0000000000000098(https://www.ahajournals.org/doi/10.1161/STR.0000000000000098)
6. Bo Z, Yi M, Li X, et al. Pharmacotherapies for central post-stroke pain: a systematic review and meta-analysis. Front Pharmacol. 2022;13:913847. https://pmc.ncbi.nlm.nih.gov/articles/PMC9410833/(https://pmc.ncbi.nlm.nih.gov/articles/PMC9410833/?utm_source=chatgpt.com)
7. Leijon G, Boivie J. Central post-stroke pain: a controlled trial of amitriptyline and carbamazepine. Pain. 1989;36(1):27-36. https://pubmed.ncbi.nlm.nih.gov/2465530/(https://pubmed.ncbi.nlm.nih.gov/2465530/?utm_source=chatgpt.com)
8. Mahesh B, Abraham A, Arivazhagan A, et al. Efficacy of duloxetine in patients with central post-stroke pain: a randomized double-blind placebo-controlled trial. Pain Med. 2023. https://pubmed.ncbi.nlm.nih.gov/36409018/(https://pubmed.ncbi.nlm.nih.gov/36409018/?utm_source=chatgpt.com)
9. Vestergaard K, Andersen G, Gottrup H, Kristensen BT, Jensen TS. Lamotrigine for central poststroke pain: a randomized controlled trial. Neurology. 2001;56(2):184-190. https://pubmed.ncbi.nlm.nih.gov/11160953/(https://pubmed.ncbi.nlm.nih.gov/11160953/?utm_source=chatgpt.com)
10. Chen KY, Li RY. Efficacy and safety of different antidepressants and anticonvulsants in central poststroke pain: a network meta-analysis and systematic review. PLoS One. 2022;17(10):e0276012. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0276012()
11. Liu Y, Zhang J, Wang J, et al. Repetitive transcranial magnetic stimulation in central post-stroke pain: a systematic review and meta-analysis. Front Neurosci. 2024;18:1367649. https://www.frontiersin.org/journals/neuroscience/articles/10.3389/fnins.2024.1367649/full(https://www.frontiersin.org/journals/neuroscience/articles/10.3389/fnins.2024.1367649/full?utm_source=chatgpt.com)
12. Farrell SM, Green AL, Aziz TZ. The current state of deep brain stimulation for chronic pain and its clinical applications. Brain Sci. 2018;8(8):158. https://www.mdpi.com/2076-3425/8/8/158(https://www.mdpi.com/2076-3425/8/8/158?utm_source=chatgpt.com)

Question 6

CHRONIC NEUROPATHIC PAIN

Accepted Answer

What is chronic neuropathic pain?

Neuropathic pain is pain caused by a lesion or disease of the somatosensory nervous system, the nerve network that carries and processes touch, temperature, and pain signals.¹ This definition matters because it separates neuropathic pain from nociceptive pain, which comes from irritated or inflamed non-nerve tissue such as muscles, joints, or skin.¹

“Chronic” usually means pain that persists or recurs for 3 months or longer.² Chronic neuropathic pain can be peripheral, meaning the injury is in nerves outside the brain and spinal cord, or central, meaning the injury is in the brain or spinal cord.²

How is neuropathic pain different from other chronic pain?

Neuropathic pain is defined by where the problem sits in the nervous system, not by how severe the pain feels.¹ Two people can have the same pain intensity, one from arthritis (nociceptive) and one from nerve injury (neuropathic), but the best treatment options often differ because the biology differs.¹²

Neuropathic pain also commonly blends with other pain types. The ICD-11 framework for chronic neuropathic pain recognizes that mixed pain states are common in real life, such as painful radiculopathy with mechanical back pain, or post-surgical nerve injury with scar and muscle pain.² When pain is mixed, the most effective plan often treats more than one driver at the same time, while still keeping each change measurable.²³

What causes chronic neuropathic pain?

There are many causes, and naming the cause is part of guiding treatment. Common peripheral causes include painful diabetic polyneuropathy, postherpetic neuralgia (after shingles), painful radiculopathy (nerve root injury or irritation), and peripheral nerve injury after trauma or surgery.²³ Central causes include pain after stroke, pain after spinal cord injury, and pain linked to multiple sclerosis.²

Cause can also mean the mechanism that keeps pain going after the initial injury. Neuropathic pain can persist when damaged nerves become overactive, when the spinal cord amplifies incoming signals, and when brain networks involved in sensation and threat detection stay sensitized. These mechanisms are described across clinical frameworks used for grading neuropathic pain and for guiding assessment and treatment decisions.³⁴

What does chronic neuropathic pain feel like?

Neuropathic pain is often described as burning, electric, stabbing, shooting, freezing, or pins-and-needles sensations. It can be constant, episodic, or layered, for example a steady burn with sudden spikes.¹³ People may also report numbness or reduced sensation in the same area, which can feel paradoxical but is common when the same pathway carries less normal sensation and more abnormal pain signaling.³⁴

Many people also notice that ordinary contact feels painful. Clothing, bedsheets, shower water, and wind can trigger pain. These features are not “imagined,” they reflect altered sensory processing in damaged pathways, and they are emphasized in neuropathic pain grading and assessment guidance.³⁴

What are allodynia and hyperalgesia, and why do they matter?

Allodynia means pain from something that normally should not hurt, such as a light touch or fabric. Hyperalgesia means an exaggerated pain response to something that normally is painful. These are common signs in neuropathic pain and are useful because they point to sensory system dysfunction rather than only tissue irritation.³⁴

They matter for treatment planning because they often change what is worth trying. For example, localized touch-evoked pain may lead a clinician to discuss topical treatments alongside systemic medications. Neuropathic assessment guidelines also emphasize mapping sensory gain and sensory loss because those patterns help confirm diagnosis and track treatment response.⁴

How do clinicians decide whether pain is truly neuropathic?

Clinicians typically combine symptom pattern, exam findings, and objective evidence of a lesion or disease affecting the somatosensory system. The widely used grading approach moves from possible to probable to definite neuropathic pain based on whether the pain distribution is neuroanatomically plausible, whether sensory signs are present on exam, and whether there is confirmatory evidence of a relevant lesion or disease.³

In practice, “definite” neuropathic pain is not required to start treatment, especially when the pattern is strongly suggestive and the suspected cause is already known. Still, better diagnostic certainty usually improves targeting, reduces trial-and-error, and helps identify when the pain is mixed and needs a broader plan.³⁴

What does a neuropathic pain exam usually include?

A focused sensory exam often checks light touch, pinprick, temperature, vibration, and whether gentle stimulation triggers pain. It also maps where sensation is reduced versus where sensation is overly sensitive, which can reveal nerve territory patterns, nerve root patterns, or central patterns.³⁴

Guidelines for neuropathic pain assessment emphasize that exam findings should be interpreted in context. A normal exam does not automatically rule out neuropathic pain, especially early in some conditions, but exam abnormalities can strengthen diagnostic confidence and guide next steps, including targeted testing when needed.⁴

Which tests can support diagnosis, and when are they used?

Tests are chosen to answer a specific question: what is the lesion or disease, where is it, and is it plausibly linked to the pain pattern. Depending on the case, this can include imaging (such as spine imaging for suspected nerve root pathology), nerve conduction studies and EMG for large-fiber neuropathies, and skin biopsy or corneal confocal microscopy for suspected small fiber neuropathy in specialized settings.⁴

The joint European Academy of Neurology, European Pain Federation, and NeuPSIG diagnostic guideline highlights that evidence quality for many diagnostic tests is poor to moderate, and that test performance varies by condition. This is why testing tends to be targeted rather than universal, and why clinical pattern plus exam remain central.⁴

Why does neuropathic pain persist even when the original injury is stable?

Once nerve pathways are injured, they can remain biologically “noisy.” Damaged nerves may fire spontaneously, adjacent neurons may become more excitable, and central pain pathways may amplify signals when inhibitory control is reduced. These mechanisms help explain why pain can outlast healing of the initial tissue injury and why symptoms can fluctuate with sleep, stress, illness, or activity load.³⁴

Treatment evidence also reflects this complexity. Updated NeuPSIG recommendations, including the 2015 and 2025 Lancet Neurology meta-analyses, show that many neuropathic pain medications have modest average benefit, with meaningful variation across individuals.⁵⁶ That reality supports a structured approach: clear diagnosis, careful trials, and a plan to switch or combine strategies when the first choice is not enough.⁶

What are realistic goals for treatment?

Most evidence-based frameworks focus on meaningful improvement rather than complete elimination of pain. Goals often include fewer flares, improved sleep, better ability to move and participate in daily life, and fewer medication side effects.⁶

It also helps to define what “working” looks like before starting a new step. NeuPSIG recommendations and NICE guidance both support structured trials and switching strategies, which depend on tracking outcomes over time rather than relying on memory alone.⁶⁷

What are the most evidence-supported medication classes for chronic neuropathic pain?

Multiple guidelines support similar first-line choices for many neuropathic pain presentations: tricyclic antidepressants (such as amitriptyline), SNRIs (such as duloxetine), and gabapentinoids (gabapentin, pregabalin).⁵⁶⁷ NICE recommends offering a choice among amitriptyline, duloxetine, gabapentin, or pregabalin as initial treatment for neuropathic pain in adults, excluding trigeminal neuralgia.⁷

NeuPSIG’s updated recommendations, supported by large systematic reviews and meta-analyses, also place these classes among the core first-line options, while emphasizing that benefit is often moderate and adverse effects are common enough to plan for.⁵⁶ This is why clinicians often start with one medication, titrate carefully, reassess, then switch or add another strategy if needed.⁶⁷

How do clinicians choose between amitriptyline, duloxetine, gabapentin, and pregabalin?

Choice usually depends on the person’s medical profile, the pain pattern, and side effect risks. For example, clinicians may think about fall risk, daytime sedation, constipation vulnerability, kidney function, and potential interactions with other medicines when selecting an initial option.⁶⁷

Guidelines also support switching when the first choice is not effective or not tolerated. NICE explicitly recommends trying one of the remaining options if the initial drug is not effective or not tolerated, and considering switching again if needed.⁷ A structured switching plan often reduces time lost in partial benefit or intolerable side effects.⁶⁷

What role do topical treatments play in chronic neuropathic pain?

Topical treatments are primarily used for localized peripheral neuropathic pain, meaning a clearly defined painful area on the skin surface that can be covered by a patch or plaster. NeuPSIG recommendations and evidence reviews describe topical lidocaine and high-concentration capsaicin as options for localized peripheral neuropathic pain, rather than for widespread or central neuropathic pain.⁵⁶⁸

Topicals can be valuable when systemic side effects are a concern, or when the pain is superficial and touch-evoked. For example, reviews describe the 5% lidocaine medicated plaster as an established option for postherpetic neuralgia and discuss its tolerability profile.⁸ Capsaicin 8% patch trials show modest pain improvement in some peripheral neuropathic pain conditions such as painful diabetic peripheral neuropathy, although response varies.⁹

What about tramadol, stronger opioids, and combination therapy?

NeuPSIG recommendations discuss tramadol as a later-line option for neuropathic pain, generally after first-line options have not provided adequate relief or have not been tolerated.⁵ This positioning reflects a balance of potential benefit against risks such as dependence, sedation, and interactions, and it also reflects that neuropathic pain often responds incompletely to opioids.⁵⁶

Combination therapy is sometimes used when partial benefit is achieved with one agent but side effects limit further dose increases. Evidence syntheses and guideline discussions acknowledge that combining approaches is common in practice, but it should be done carefully, with attention to additive side effects such as sedation and dizziness.⁵⁶ This is a place where decision-support discussions with a clinician are especially important, since the “right” combination depends heavily on medical history.⁶⁷

What non-drug strategies are part of evidence-based care?

Non-drug strategies are part of standard neuropathic pain care because pain is shaped by activity patterns, sleep, stress physiology, and nervous system sensitivity. Neuropathic pain assessment guidance supports evaluating these factors because they can amplify symptoms and because improvements here can strengthen medication effectiveness.⁴

The following approaches focus on reducing triggers, improving function, and lowering the nervous system’s overall load:
 • Education and pacing: building predictable activity, avoiding boom-bust cycles, and planning recovery after known triggers.⁶
 • Physical and occupational therapy: movement strategies, ergonomic changes, nerve-protective habits, and desensitization approaches when touch sensitivity is prominent and the clinician feels it fits the pain mechanism.⁴
 • Psychological strategies as part of multimodal care: skills that reduce distress and disability, which can improve quality of life even when nerve injury persists. NeuPSIG’s evidence syntheses support multimodal care because medication effects alone are often modest.⁶

When are neuromodulation and procedures considered, and what do they include?

Neuromodulation means using electrical stimulation to change pain signaling within the nervous system. It includes noninvasive approaches and implanted therapies. It is generally considered when pain remains function-limiting despite structured trials of first-line treatments and when the diagnosis and pain distribution match a therapy with evidence.¹⁰

Options include spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRG-S), peripheral nerve stimulation, and in rarer cases, brain stimulation approaches. The Lancet Series on neuromodulation emphasizes that outcomes depend strongly on diagnosis, patient selection, and long-term follow-up, and that evidence strength varies across indications.¹⁰

What do we know about spinal cord stimulation for neuropathic pain?

SCS is one of the most studied implanted neuromodulation therapies for neuropathic pain, but evidence strength varies by condition. A randomized clinical trial in JAMA Neurology found that 10 kHz SCS plus conventional medical management improved outcomes in patients with painful diabetic neuropathy refractory to medical management, with a much higher responder rate compared with medical management alone.¹¹

This does not mean SCS is appropriate for every neuropathic pain condition. It means there is strong trial evidence for selected populations and protocols, and that referral decisions should be diagnosis-specific, not based on a generic idea of “nerve pain.”¹⁰¹¹

What is dorsal root ganglion stimulation, and when might it be discussed?

DRG stimulation targets the dorsal root ganglion, a structure that relays sensory signals from specific body regions. It is often discussed when pain is focal and anatomically specific, and when precise coverage matters, especially in certain regional pain syndromes.¹⁰

A randomized comparative trial in Pain, commonly referred to as the ACCURATE trial, reported higher treatment success rates for DRG stimulation compared with traditional SCS in complex regional pain syndrome and causalgia at 3 and 12 months.¹² While this evidence is not about every neuropathic pain condition, it supports the concept that matching therapy to pain distribution can improve outcomes.¹⁰¹²

Where does deep brain stimulation fit for chronic neuropathic pain?

Deep brain stimulation (DBS) for pain involves implanting electrodes in deep brain targets involved in pain perception and modulation, including sensory thalamic targets and brainstem-adjacent targets such as periaqueductal or periventricular gray, among others described in chronic pain DBS literature.¹³

DBS is not a standard pathway for most chronic neuropathic pain. Reviews describe variable outcomes, limited high-quality trials, and the reality that DBS is generally reserved for highly selected, treatment-refractory cases in expert centers.¹⁰¹³ If DBS is raised in conversation, it usually signals a high-complexity situation where uncertainty, surgical risk, and long-term follow-up demands must be weighed carefully.¹⁰¹³

How do availability and care pathways differ by country?

Across the US, Canada, UK, EU, and other regions, the core principles are similar: confirm the neuropathic mechanism, start with evidence-supported medications, reassess, and consider specialty referral for refractory cases.⁴⁶⁷

What differs the most is access sucha as: which medications are covered, how gabapentinoids and opioids are regulated, and how available neuromodulation services are. NICE guidance directly shapes UK pathways, while NeuPSIG and EAN, EFIC recommendations are widely referenced internationally.⁴⁶⁷

What can I track to help my medical team tailor treatment?

Tracking improves precision. It helps your team decide whether a treatment is reducing pain intensity, shortening flare duration, improving sleep, or improving function, and it helps detect side effects early enough to adjust safely.⁶⁷

These are most commonly used to guides for next-step decisions:
 • Pain map: where it is, whether it follows a nerve or root pattern, and whether the painful area is localized or widespread.³⁴
 • Pain quality: burning, electric, stabbing, numbness, tingling, pressure, and whether touch triggers pain.¹³
 • Sensory triggers: clothing, bedding, shower water, temperature change, wind, and gentle touch.⁴
 • Function outcomes: sleep, walking, work tasks, concentration, self-care, and ability to tolerate activity.⁶
 • Treatment log: start date, dose changes, benefits, side effects, and why something was stopped or switched.⁷

What questions can I bring to my next appointment?

These questions support shared planning and reduce guesswork, especially when you have tried several options without a clear structure.

The goal is a stepwise plan with clear trial windows and clear definitions of success:
 • Does my pain meet criteria for possible, probable, or definite neuropathic pain, and what supports that classification?³
 • What is the most likely cause in my case, and what tests, if any, would confirm it?²⁴
 • Which first-line medication class fits my health profile best, and what is our plan if it does not help or causes side effects?⁶⁷
 • Is my pain localized enough for topical lidocaine or capsaicin to be reasonable, or is it widespread or central where topicals are less likely to help?⁵⁶⁸
 • When should we discuss referral to a pain specialist or neuromodulation center, and which option fits my diagnosis and pain distribution?¹⁰¹¹¹²
 • What outcome will we use to define progress, fewer flares, better sleep, improved function, fewer side effects, or a meaningful drop in pain intensity?⁶⁷

SAFETY NOTE
This page is educational and can’t diagnose or treat. If symptoms are urgent, sudden, or severe, or you feel unsafe, seek emergency care right away.

GLOSSARY
Allodynia: Pain from something that normally shouldn’t hurt, such as light touch or clothing.
Capsaicin 8% Patch: A high-concentration topical treatment used for certain localized peripheral neuropathic pain conditions.
Central Neuropathic Pain: Neuropathic pain caused by injury or disease in the brain or spinal cord.
Chronic Pain: Pain that persists or recurs for at least 3 months.
Dorsal Root Ganglion: A cluster of sensory nerve cell bodies near the spine that relays sensation from a specific body region.
Dorsal Root Ganglion Stimulation (DRG-S): An implanted therapy that stimulates the dorsal root ganglion to reduce pain in targeted areas.
Duloxetine: An SNRI antidepressant that is also used for some neuropathic pain conditions.
Gabapentin: A gabapentinoid medication used for neuropathic pain in some patients.
Hyperalgesia: Increased pain response to something that is normally painful.
Lesion: Damage or injury to tissue, such as a nerve or part of the nervous system.
NeuPSIG: The Neuropathic Pain Special Interest Group of the International Association for the Study of Pain.
Neuromodulation: Use of electrical stimulation to change nerve or brain signaling involved in pain.
Neuropathic Pain: Pain caused by a lesion or disease of the somatosensory nervous system.
Nociceptive Pain: Pain arising from actual or threatened damage to non-nerve tissue, due to activation of nociceptors.
Peripheral Neuropathic Pain: Neuropathic pain caused by injury or disease in nerves outside the brain and spinal cord.
Pregabalin: A gabapentinoid medication used for neuropathic pain in some patients.
Somatosensory Nervous System: The nerves and brain pathways that carry and interpret sensation, including touch, temperature, and pain.
Spinal Cord Stimulation (SCS): An implanted therapy that delivers electrical stimulation near the spinal cord to reduce pain signaling.
Tramadol: An opioid-like pain medication sometimes used later in treatment pathways for neuropathic pain under careful supervision.

REFERENCES
1. International Association for the Study of Pain. Terminology: Neuropathic pain; nociceptive pain. https://www.iasp-pain.org/resources/terminology/(https://www.iasp-pain.org/resources/terminology/?utm_source=chatgpt.com)
2. Scholz J, Finnerup NB, Attal N, et al. The IASP classification of chronic pain for ICD-11: chronic neuropathic pain. Pain. 2019;160(1):53-59. https://journals.lww.com/pain/fulltext/2019/01000/the_iasp_classification_of_chronic_pain_for.7.aspx(https://journals.lww.com/pain/fulltext/2019/01000/the_iasp_classification_of_chronic_pain_for.7.aspx?utm_source=chatgpt.com)
3. Finnerup NB, Haroutounian S, Kamerman P, et al. Neuropathic pain: an updated grading system for research and clinical practice. Pain. 2016;157(8):1599-1606. https://pmc.ncbi.nlm.nih.gov/articles/PMC4949003/(https://pmc.ncbi.nlm.nih.gov/articles/PMC4949003/?utm_source=chatgpt.com)
4. Truini A, Aleksovska K, Anderson CC, et al. Joint European Academy of Neurology–European Pain Federation (EFIC)–NeuPSIG guidelines on neuropathic pain assessment: diagnosis. Eur J Neurol. 2023. https://onlinelibrary.wiley.com/doi/10.1111/ene.15831(https://onlinelibrary.wiley.com/doi/10.1111/ene.15831?utm_source=chatgpt.com)
5. Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: systematic review, meta-analysis and updated NeuPSIG recommendations. Lancet Neurol. 2015;14(2):162-173. https://pmc.ncbi.nlm.nih.gov/articles/PMC4493167/(https://pmc.ncbi.nlm.nih.gov/articles/PMC4493167/?utm_source=chatgpt.com)
6. Soliman N, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2025. https://www.thelancet.com/journals/laneur/article/PIIS1474-4422%2825%2900068-7/fulltext()
7. National Institute for Health and Care Excellence. Neuropathic pain in adults: pharmacological management in non-specialist settings (CG173). https://www.nice.org.uk/guidance/cg173/chapter/1-recommendations(https://www.nice.org.uk/guidance/cg173/chapter/1-recommendations?utm_source=chatgpt.com)
8. de León-Casasola OA, Mayoral V, Coluzzi F, et al. The topical 5% lidocaine medicated plaster in localized neuropathic pain: a reappraisal. J Pain Res. 2016;9:67-79. https://pmc.ncbi.nlm.nih.gov/articles/PMC4758786/(https://pmc.ncbi.nlm.nih.gov/articles/PMC4758786/?utm_source=chatgpt.com)
9. Simpson DM, Robinson-Papp J, Van J, et al. Capsaicin 8% patch in painful diabetic peripheral neuropathy: a randomized, double-blind, placebo-controlled study. J Pain. 2017;18(1):42-53. https://www.jpain.org/article/S1526-5900%2816%2930244-9/fulltext(https://www.jpain.org/article/S1526-5900%2816%2930244-9/fulltext)
10. Knotkova H, Hamani C, Sivanesan E, et al. Neuromodulation for chronic pain. Lancet. 2021;397(10289):2111-2124. https://pubmed.ncbi.nlm.nih.gov/34062145/(https://pubmed.ncbi.nlm.nih.gov/34062145/?utm_source=chatgpt.com)
11. Petersen EA, Stauss TG, Scowcroft JA, et al. Effect of high-frequency (10-kHz) spinal cord stimulation in patients with painful diabetic neuropathy: a randomized clinical trial. JAMA Neurol. 2021;78(6):687-698. https://jamanetwork.com/journals/jamaneurology/fullarticle/2777806(https://jamanetwork.com/journals/jamaneurology/fullarticle/2777806?utm_source=chatgpt.com)
12. Deer TR, Levy RM, Kramer J, et al. Dorsal root ganglion stimulation yielded higher treatment success rate for complex regional pain syndrome and causalgia at 3 and 12 months: a randomized comparative trial. Pain. 2017;158(4):669-681. https://journals.lww.com/pain/fulltext/2017/04000/dorsal_root_ganglion_stimulation_yielded_higher.14.aspx(https://journals.lww.com/pain/fulltext/2017/04000/dorsal_root_ganglion_stimulation_yielded_higher.14.aspx?utm_source=chatgpt.com)
13. Farrell SM, Green A, Aziz TZ. The current state of deep brain stimulation for chronic pain and its clinical applications. Brain Sci. 2018;8(8):158. https://www.mdpi.com/2076-3425/8/8/158(https://www.mdpi.com/2076-3425/8/8/158?utm_source=chatgpt.com)

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