Page 206 Guide to Pain Management in Low-Resource Settings

194 Maija Haanpää and Aki Hietaharju

Gabapentin has the same mechanism of action and can Pearls of wisdom
be used instead. It is started with 300 mg in the evening,
and the dose is escalated in steps of 300 mg daily or ev- • Central neuropathic pain may be present from
ery other day. Th e daily dose is divided into three dos- the start of the neurological symptoms or may
es. Th e eff ective dose is 900–3600 mg/day, divided into appear after a delay of days, months, or even
three daily doses. Gabapentin has no pharmacokinetic years.
interactions. It can be tried also for central poststroke • Th e most common qualities of central pain are
pain if amitriptyline and carbamazepine fail. burning, pricking, and pressing.
Central neuropathic pain is unfortunately quite • Remember that nearly all patients with central
refractory to treatment, and pain relief is usually only neuropathic pain have abnormalities of pain and
partial. Based on information from open studies and temperature sensation.
clinical experience, transcutaneous electrical nerve • Amitriptyline, carbamazepine, and gabapentin
stimulation (TENS) can be helpful for central pain in can be used for symptomatic treatment.
cases where there is well-preserved sensibility to vibra-
tion and touch. References

[1] Attal N, Cruccu G, Haanpää M, Hansson P, Jensen TS, Nurmikko
What is the prognosis of central T, Sampaio C, Sindrup S, Wiff en P. EFNS Task Force. EFNS guide-
neuropathic pain? lines on pharmacological treatment of neuropathic pain. Eur J Neurol
2006;13:1153–69. (Current evidence and practical guidelines on phar-
macotherapy of neuropathic pain)
Th e natural course of central pain is not known exactly. [2] Moseley GL, Gallace A, Spence C. Is mirror therapy all it is cracked
up to be? Current evidence and future directions. Pain 2008;138:7–10.
Resolution of pain has been reported in 20% of patients (Current evidence and practical information of mirror therapy)
[3] Ofek H, Defrin R. Th e characteristics of chronic central pain after trau-
with central poststroke pain, occurring over a period of matic brain injury. Pain 2007;131:330–40. (Describes central neuro-
years. It is still not known whether treatment of the pain pathic pain after brain injury)
has any modifying eff ect on the duration of central neu-
ropathic pain.