Phantom limb pain and central post-stroke pain

Central post-stroke pain is burning or aching pain in the stroke-affected territory, often after thalamic or brainstem lesions, treated like other neuropathic pain; phantom limb pain is common after amputation, and mirror therapy is the most studied nondrug option.

1. Central post-stroke pain appears after a latency. It is neuropathic pain in part of the body affected by hemorrhagic or ischemic stroke, usually developing within a few months ¹.
2. Lesion site matters. Thalamic and brainstem lesions are more likely to cause central neuropathic pain than lesions elsewhere ¹.
3. The sensory picture is mixed. Burning, aching or stabbing pain combines hypo- and hypersensitivity; over 90% have thermal, especially cold, sensory abnormalities, while touch and vibration deficits are less common ¹.
4. Treat as central neuropathic pain. Amitriptyline is widely supported as first-line for post-stroke pain, with gabapentinoids, duloxetine and lamotrigine as options; NeuPSIG 2025 lists gabapentinoids, SNRIs and TCAs as first-line for neuropathic pain generally ¹².
5. Phantom limb pain is very common. About 80% of amputees report it in the first year and up to 87% at some point ³.
6. Mirror therapy is the leading nondrug option. Reflected movement of the intact limb gives the illusion that the missing limb moves; in 32 studies, 21 reported clinically significant reduction, but protocols vary widely. Phantom pain is linked to peripheral and central changes, including cortical reorganization ³.

Not all pain after stroke is central: shoulder pain and other post-stroke pains must be distinguished, and the lack of clear diagnostic criteria makes prevalence estimates uncertain ¹.

• Central post-stroke pain affects about 1–12% of stroke patients, reportedly up to 55% ¹.
• Intermittent dysesthesia occurs in up to 85% of central post-stroke pain patients ¹.
• Amitriptyline is typically given at about 75 mg/day for central post-stroke pain ¹.
• In a mixed neuropathic cohort including central post-stroke pain, oral opioids lowered pain by about 23% on average ¹.
• Refractory central post-stroke pain may be considered for deep brain or motor cortex stimulation ¹.
• Mirror therapy versus covered-mirror sham showed no significant difference, suggesting phantom motor execution may be the active component ³.
• Virtual mirror therapy delivers visual feedback digitally and can track adherence in home programs ³.
• No unanimous consensus exists on mirror therapy setting, technique, session frequency or duration ³.

• Treating central post-stroke pain with opioids first; they are not first-line ¹.
• Expecting central post-stroke pain immediately at stroke onset; there is usually a latency, with onset often within a few months ¹.
• Assuming a single standard mirror therapy protocol exists ³.