Pain after stroke - Stroke Association
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Call the Stroke Helpline: 0303 3033 100
or email: info@stroke.org.uk
Pain after stroke
This guide will help you to understand some of the causes of pain after
stroke, and the treatments that are available. It also gives details of
useful organisations that can provide information and support.
After a stroke, around 30% of survivors or hypertonia. A stroke can cause muscle
experience pain. This is most likely to happen weakness down one side, also known
soon after a stroke, but can also develop as hemiparesis. Spasticity affects the
some time later. Types of post-stroke pain weakened muscles, often in the arms and
include muscle and joint pain, headaches, hands, but also in the legs. It may affect up
and painful sensations like tingling. Some of to a third of of stroke survivors. If it’s not
the main types of pain are: treated, spasticity can lead to the muscles
being permanently shortened. The joints
• spasticity and contractures and muscles can become so stiff that it
is impossible to move them, causing a
• shoulder pain contracture.
• central post-stroke pain How is spasticity treated?
• other conditions, including swollen If you have muscle weakness after your
hands and headaches. stroke you should be assessed for spasticity,
and receive therapy to reduce the risk of
Depending on the cause of the pain, contractures. Treatments may include a
treatments like medication and physiotherapy combination of physiotherapy, injections
are often helpful. Some causes of pain can be of botulinum toxin type A and other
treated, but for some people, post-stroke pain medications.
can last a long time. This guide also examines
techniques like pain clinics and TENS devices Physiotherapy
for managing any long-term pain. If you have spasticity you should have
physiotherapy every day to move your
Spasticity and contractures joints. This will help to stretch your
muscles, keeping them flexible and
A stroke can damage the way the nerves reducing the possibility of contractures.
control your muscles. This can lead to Your physiotherapist will gently place
muscles contracting for long periods or your affected limb into as many different
going into spasm, which can be painful. This positions as possible using techniques called
muscle tightness is known as spasticity, positioning, passive movement and active
For more information visit stroke.org.uk 1Pain after stroke
movement. See our guide F16, Physiotherapy You will usually be prescribed baclofen or
after stroke for more information. tizanidine first. If these drugs do not work,
there are other drugs that may help, but they
Botulinum toxin type A should only be prescribed by someone who
You may be given botulinum toxin type A as specialises in managing spasticity.
an injection directly into your muscle. The
main brand names used for this treatment How are contractures treated?
are Botox, Dysport and Xeomin. Botulinum
toxin type A works by blocking the action Splinting and casting
of the nerves on the muscle, reducing your If you develop contractures, your
muscle’s ability to contract. This reduces physiotherapist may use a splint or a cast
muscle tone (makes the muscle less tight), that moulds to or lies along your affected
which can help you to straighten out your limb and holds it in place. This treatment
limbs. This treatment is mainly used for helps to stretch out the muscles in your
post-stroke spasticity in the hands, wrists tight limbs and is usually combined with
and ankles. The muscle-relaxing effects of physiotherapy. Sometimes this treatment
botulinum toxin type A usually last for about is used to try to prevent contractures from
three months, and you should not notice any forming by making sure that your body is
changes in sensation in your muscles. not in an abnormal position. Unfortunately
sometimes splints and casts can be
The treatment should be given with further uncomfortable. Talk to your physiotherapist
rehabilitation such as physiotherapy, or about what would be best for you.
other treatments like splinting or casting to
ensure that any range gained in the muscle Shoulder pain
is maintained. You should also have an
assessment three to four months after the Shoulder pain affects up to a quarter of
treatment, and be offered further injections stroke survivors, and usually happens on
if they are considered helpful. the side of your body that is affected by the
stroke. There are many different conditions
Medication that cause shoulder pain and while some
If you have generalised spasticity, or if improve with targeted treatment, it
botulinum toxin treatment doesn’t reduce sometimes becomes a long-term condition.
spasticity in the injected muscle, other
types of medication can help reduce Frozen shoulder
stiffness and pain that often comes with
spasticity. There are different types of After a stroke you may find that your shoulder
drugs that you could be given. They all work is very stiff and that it hurts when you move
in slightly different ways, but they all help to it. This is called frozen shoulder, or capsulitis.
relax your muscles. When your muscles are The shoulder is a ‘ball and socket’ joint, with
relaxed they can move more easily and you a rounded shape at the end of the upper arm
can stretch them further. You may also find fitting into a hollow space in the shoulder
that it becomes easier to straighten or bend blade. Muscles and ligaments hold the arm
your affected limbs, and you may notice bone in place. There is a layer of tissue that
fewer muscle spasms. surrounds this joint which is called a capsule.
2 Call the Stroke Helpline on 0303 3033 100Pain after stroke
If your arm muscles are very weak, stiff or Shoulder taping or orthotic supports may be
paralysed, the effect of gravity puts a strain useful. However they should be prescribed by
on your ligaments and your capsule. This can your therapist, with clear guidance on usage.
cause these parts of your shoulder joint to Supports should be regularly monitored and
become inflamed, stretched and damaged. should not stop you moving your arm.
Having weakness in your arm muscles may
contribute to this pain in your shoulder. Your physiotherapist may also use electrical
stimulation on the muscles around
Subluxation your shoulder to help prevent or reduce
subluxation. If this is prescribed, the device
Another cause of shoulder pain is shoulder often needs to be used throughout the
subluxation. This means partial dislocation, day, following the advice of your therapist.
when the rounded end of the upper arm See the Alternative methods of treating pain
bone moves slightly out of its socket. This section later in this guide.
might be because the muscles that normally
hold this joint in place are too weak to do this Reducing pain
properly. You may be given painkillers such as
paracetamol or codeine to help relieve
How is shoulder pain treated? the pain in your shoulder. For more severe
pain you may be given a non-steroidal
Prevention anti-inflammatory drug (NSAID) such as
If you have weakness in your arm following ibuprofen. These types of drug help to
your stroke, your medical team will try to relieve pain and can also help to reduce
prevent shoulder pain developing. They will swelling in your shoulder capsule (the tissue
make sure that anyone who handles your arm around the shoulder joint).
knows how to do so with care and without
causing strain on your shoulder joint. If you also have inflammatory arthritis, a
steroid, such as triamcinolone, may be
They should also ensure that your arm and injected into your joint to help reduce
shoulder are positioned correctly. Correct the pain.
positioning is vital because it can help to
reduce the strain on your ligaments and Moving your shoulder
capsule, helping to prevent frozen shoulder It is important to keep the muscles in your
from developing. It may also help to prevent shoulder and arm active so that any stiffness
your shoulder blade and upper arm bone does not get worse. Your physiotherapist
from moving apart (subluxation). may use stretching exercises to move your
shoulder joint in all directions. They can
Your medical team may use foam supports also provide you with advice about how
to make sure that your shoulder is supported to protect your shoulder during everyday
in the correct position. Your arm can also be movements such as reaching for something
supported using a pillow. or getting dressed.
For more information visit stroke.org.uk 3Pain after stroke
Central post-stroke pain (CPSP) is a procedure where small electrical leads
are placed deep within your brain and are
Up to 20% of people who have a stroke may connected to a battery-powered machine,
develop central post-stroke pain (CPSP). which sits under your skin. This procedure
This problem may occur if structures in the can only be carried out in specialist centres,
brain that interpret pain are affected by the and is not routinely available on the NHS. It is
stroke. It is often diagnosed by excluding not suitable for everyone, and success rates
other more common causes first. This is also after one year of treating pain with DBS are
known as neuropathic pain, or central pain still very variable.
syndrome.
Other painful conditions
There are different types of pain you might
experience if you have CPSP. Many people Swollen hand
describe it as a burning or burning cold
sensation, or a throbbing or shooting pain. Developing a swollen hand can happen if you
Some people also experience pins and are not moving your hand very much, or are
needles or numbness in the areas affected unable to move it. Older patients and those
by the pain. For most stroke survivors who have experienced more severe strokes
with CPSP, the pain occurs in the side of are most likely to experience this condition.
their body that has been affected by the The swelling may happen because fluid builds
stroke. The pain may begin immediately up in the tissue if the muscles are not moving
after your stroke but more often it begins around. It’s more likely to happen if the hand
several months later. Some people find is hanging downwards. The painful swelling
this pain becomes worse because of other can make it more difficult to move your hand
factors such as movement or a change in and arm, which can make spasticity worse.
temperature.
To overcome this problem it is best to
How is CPSP treated? raise your hand and place it on a pillow or a
cushion, and to get your hand moving again
Ordinary painkillers such as paracetamol or gently with the help of your physiotherapist.
ibuprofen are not helpful in relieving CPSP.
Some other types of drug can be helpful, Headache
including antidepressants and anti-epilepsy
drugs. If the first medication you try does There are many reasons why you might
not work, you should be offered another experience headaches following your stroke.
drug to try with, or instead of, the first one. Some reasons might be the same as before
your stroke, such as migraines, stress, or
Other approaches to reducing pain include lack of sleep.
pain clinics and TENS (transcutanious
electrical nerve stimulation). If you are having headaches after your stroke,
they could be a side effect of medication. If
In rare cases, if your pain is severe and other you think that a medication may be causing
treatments have been unsuccessful, you may your headaches, visit your GP. They can find
be offered deep brain stimulation (DBS). This out what could be behind your headaches,
4 Call the Stroke Helpline on 0303 3033 100Pain after stroke
and can give you alternative medications if If you have a persistent headache, you
necessary. Don’t stop any treatments before should seek medical attention urgently.
talking to your doctor, as some types of drug If you have any of the signs of a stroke,
depend on being taken regularly. including a sudden, severe headache,
call 999.
A headache can be caused by a stroke, such
as a subarachnoid haemorrhage (SAH). Alternative methods of treating
SAH is a stroke caused by bleeding on the pain
surface of the brain. One of the symptoms
of SAH is a severe headache, and after a If you find that medication and or
stroke the headache may take a while to go physiotherapy has not helped to relieve your
completely. pain, you may wish to try some alternative
techniques. You may gain temporary relief
Headaches soon after SAH can be due to from TENS, massage or acupuncture.
hydrocephalus. This is a build-up of the Learning a relaxation technique, such as
cerebrospinal fluid (CSF) which surrounds meditation or yoga, having psychological
the brain and spinal cord. If the CSF can’t therapy such as counselling, or attending a
drain due to bleeding in the brain, the pain clinic may be helpful.
increased levels of fluid can cause headache,
nausea and balance problems. This can be Transcutaneous electrical nerve
treated with an operation to drain the fluid stimulation (TENS)
by inserting a thin tube, called a shunt, to
drain the fluid away from the brain. TENS treatment uses electrical impulses
to reduce pain. Sticky pads are attached to
Headaches can usually be controlled by your skin and linked to electrodes, which are
painkillers such as paracetamol. You should attached to a battery-operated machine.
not take aspirin if your stroke was caused by Electrical impulses are then sent through the
a bleed (haemorrhagic stroke). electrodes onto your skin. These impulses
can help to block the pain signals from
Drinking plenty of water (around two litres travelling along the nerve pathways to your
a day) and avoiding caffeine and alcohol brain. At a low frequency, TENS can help
can help you to stay hydrated and reduce your body to release natural painkillers called
headaches. Migraines may be triggered by endorphins.
fatigue, which is common after stroke.
There is not enough evidence to say
Sometimes, taking painkillers for headaches definitively whether TENS is an effective
too often (for more than about 10 days a and reliable way of reducing pain. It provides
month) can cause medication over-use temporary pain relief with no side effects,
headaches. Treatment usually involves other than possible skin redness. You
stopping all pain relief medication for one should ask your doctor before using it if you
month. However, you should visit your have a heart pacemaker or other type of
GP before doing so, as some painkillers electrical or metal implant in your body. It
contain codeine which can cause withdrawal may not be suitable early in pregnancy, or
symptoms if you stop taking it suddenly. for people with epilepsy or heart problems.
For more information visit stroke.org.uk 5Pain after stroke
Pain clinics and pain management Where to get help and
programmes information
Pain clinics and pain management programmes From the Stroke Association
can help you find ways to manage your pain in
the longer-term to improve your quality of life. Talk to us
If you are in pain despite initial treatment, and it Our Stroke Helpline is for anyone affected by
is causing you distress or significantly limiting a stroke, including family, friends and carers.
what you are able to do, ask your GP to refer The Helpline can give you information and
you to a pain clinic. support on any aspect of stroke.
Pain clinics provide different treatments Call us on 0303 3033 100, from a textphone
and advice to help you manage your pain. 18001 0303 3033 100
The kinds of treatment that are available or email info@stroke.org.uk.
from pain clinics vary across the UK. More
information about what pain services are Read our publications
available for you can be obtained from your We publish detailed information about a wide
local health service, for example your GP. range of stroke topics including reducing
your risk of a stroke and rehabilitation. Read
Some pain clinics run pain management online at stroke.org.uk or call the Helpline to
programmes. They use psychological and ask for printed copies.
practical methods to deal with managing
your pain, and the effect that it has on your My Stroke Guide
life. Carried out in groups, the programmes My Stroke Guide is the online stroke support
usually run for a set amount of time over tool from the Stroke Association. Log on to
a number of weeks. Doctors, nurses, find easy-to-read information, advice and
psychologists, physiotherapists and videos about stroke. And our chat forums
occupational therapists may be involved can connect you to our online community,
with the programme. For example, a to hear how others manage their recovery.
physiotherapist might help you to work Log on at mystrokeguide.com.
on the physical difficulties that the pain
causes by strengthening your muscles, and a Our dedicated Enquiry Line is on hand
psychologist might help you to manage the to support you with using My Stroke
emotional effects that pain can have, such as Guide. Call 0300 222 5707 or email
depression and frustration. mystrokeguide@stroke.org.uk.
6 Call the Stroke Helpline on 0303 3033 100Pain after stroke
Other sources of help and The Pain Relief Foundation
information Website: www.painrelieffoundation.org.uk
Tel: 0151 529 5820
Websites Provides information about pain and pain
management and supports research into
Action on pain treatments. Publishes CDs and books that
Website: www.action-on-pain.co.uk aim to help people cope with different types of
PainLine: 0345 603 1593 pain, including headache, back and joint pain.
A charity run by volunteers who are all
affected by chronic pain in some way. PainSupport
Provides information and advice about pain, Website: www.painsupport.co.uk
and raises awareness of those living with Provides information about pain relief and
chronic pain. advice about treatments. Offers an online
forum and a contact club so that people
The British Pain Society suffering from pain can contact each other.
Website: www.britishpainsociety.org
Tel: 020 7269 7840 SCOPE
Produces booklets about different types of Website: www.scope.org.uk
pain and how they can be treated. Includes a Helpline: 0808 800 3333
glossary of pain-related words and phrases. Provides information sheets about
spasticity, splinting and botulinum toxin
Chronic Pain Policy Coalition type A treatment.
Website: www.policyconnect.org.uk/cppc
A forum uniting professionals, members TMS Healthcare
of parliament and patients to campaign Tel: 0121 355 6555
for improved strategies on chronic pain Website: www.tens.co.uk
issues. Information about pain is available on An online shop that sells TENS machines and
the website. other pain management aids.
Pain Association Scotland Books
Website: www.painassociation.com
Tel: 0800 783 6059 The Pain Relief Handbook: Self-help
Provides information about pain and runs methods for managing pain
self-management programmes across Dr Chris Wells & Graham Nown Vermilion
Scotland for people living with chronic pain. 1996, Firefly Books
Pain Concern Taking Control of your Pain
Website: www.painconcern.org.uk Toni Battison
Helpline: 0300 123 0789 2005, Age Concern Books
Information and advice about pain is
available through a range of publications and Pain Relief without Drugs
their helpline. Runs a radio programme called Jan Sadler
Airing Pain. They also have an online forum. 2007, Healing Arts Press
For more information visit stroke.org.uk 7Pain after stroke
Glossary About our information
Contracture = permanent shortening of a We want to provide the best information for
muscle that can leave a limb in an abnormal people affected by stroke. That’s why we
position. ask stroke survivors and their families, as
well as medical experts, to help us put our
Frozen shoulder = a very stiff shoulder which publications together.
can be painful.
How did we do?
Spasticity = a form of muscle tightening. To tell us what you think of this guide, or to
request a list of the sources we used to create
Subarachnoid haemorrhage = a type of it, email us at feedback@stroke.org.uk.
stroke caused by bleeding in the space
between the brain and skull. Accessible formats
Visit our website if you need this information
Subluxation = partial dislocation of the in audio, large print or braille.
shoulder, where the bone of the upper arm
and the shoulder blade have moved apart. Always get individual advice
Please be aware that this information is
TENS = Transcutaneous electrical nerve not intended as a substitute for specialist
stimulation (a treatment that uses electrical professional advice tailored to your situation.
impulses to block pain signals). We strive to ensure that the content we
provide is accurate and up-to-date, but
information can change over time. So far as is
We would like to thank Allergan, permitted by law, the Stroke Association does
Ipsen and Merz for funding the cost not accept any liability in relation to the use
of producing this guide. The Stroke of the information in this publication, or any
Association keeps full independent third-party information or websites included
control over all content. or referred to.
© Stroke Association 2018
Version 2.1. Published April 2018
To be reviewed: September 2020
Item code: A01F30
We rely on your support to fund life-saving research and vital services for people
affected by stroke. Join the fight against stroke now at stroke.org.uk/fundraising
Together we can conquer stroke.
The Stroke Association is registered as a charity in England and Wales (No 211015) and in Scotland (SC037789).
Also registered in Northern Ireland (XT33805), Isle of Man (No 945) and Jersey (NPO 369).
For more information visit stroke.org.uk 8You can also read
