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Central poststroke pain
Central pain develops in 8% to 35% of stroke patients; its pathophysiology and treatment
options have been reviewed by Kumar et al (Kumar et al, 2009). Intravenous lignocaine (Attal et
al, 2000 Level II) and IV propofol in subhypnotic doses (Canavero & Bonicalzi, 2004 Level II) may
provide short‐term relief in central poststroke pain, and amitriptyline was more effective than
placebo and carbamazepine (which was not different from placebo) (Leijon & Boivie, 1989
Level II). Lamotrigine was moderately effective and well‐tolerated in central poststroke pain
(Vestergaard et al, 2001 Level II).
Trigeminal neuralgia
Excerbations of trigeminal neuralgia can present as acute neuropathic pain. Published
guidelines identified insufficient evidence for the effectiveness of any IV medication in this
setting (Cruccu et al, 2008 Level I). The same guidelines rate carbamazepine as effective and
oxcarbazepine as probably effective in this condition and suggest that baclofen, lamotrigine,
and pimozide may be considered if the first line medications are ineffective. Topical
ophthalmic anaesthesia is described as probably ineffective.
Guillain-Barre syndrome
See Section 9.8.4.
Key message
The following tick box represents conclusions based on clinical experience and expert
opinion.
Treatment of acute pain associated with neurological disorders is based largely on
evidence from trials for the treatment of a variety of chronic neuropathic pain states.
9.6.7 Orofacial pain
Acute orofacial pain may be caused by infective, traumatic, neuropathic, vascular, neoplastic
or other pathologies (Zakrzewska & Harrison, 2003; Keith, 2004; Ward & Levin, 2004). Most
commonly acute orofacial pain is due to dental or sinus disease but it may also be associated
with chronic facial pain syndromes (eg trigeminal neuralgia) or be referred from adjacent
regions such as the cervical spine and the thorax. A thorough history (including dental) and
examination (particularly of the oral cavity and cranial nerves) are essential components of the CHAPTER 9
assessment of orofacial pain. Recurrent or persistent orofacial pain requires a biopsychosocial
assessment and appropriate multidisciplinary management (Vickers et al, 2000). Neuropathic
orofacial pain (atypical odontalgia, phantom pain) may be exacerbated by repeated dental
procedures (eg extraction of teeth, root canal therapy, sectioning of nerves), incorrect drug
therapy or psychological factors (Vickers et al, 1998).
Acute postoperative dental pain
Acute pain after third molar extraction is the most extensively studied model for testing
postoperative analgesics. Ibuprofen, paracetamol, aspirin (Barden et al, 2004 Level I) and
celecoxib (Derry et al, 2008 Level I; Cheung et al, 2007 Level II) were found to be effective in this
setting. Interestingly, the placebo response for analgesia was significantly lower in postdental
extraction pain than in other acute pain models (Barden et al, 2004 Level I).
NsNSAIDs or coxibs were recommended as ‘first‐line’ analgesics following third molar
extraction (Barden et al, 2004 Level I), however paracetamol was also safe and effective (Weil
et al, 2007 Level I), with a dose of 1000 mg providing better pain relief than lower doses (NNT 3;
NNH 33) (Dodson, 2007 Level I). NsNSAIDs were more effective than paracetamol or codeine
Acute pain management: scientific evidence 273
