Central pain: diagnosis and treatment strategies.

The pathophysiology of central pain (CP) remains poorly understood. The paucity of objective findings on clinical examination of some of these patients can add to the difficulty in establishing a concrete diagnosis of CP. A pathophysiologic conceptual framework has been established to provide guidance. The goal of treatment should be pain reduction rather than complete pain relief. Surgical procedures have been used for specific causes of CP, but no one surgical technique helps relieve pain over the long term in all CP patients. Likewise, no one pharmacologic agent is successful in all CP patients, and pain relief is often incomplete. Pharmacologic treatment may take the form of stepwise addition of various agents, the cornerstone of which are antidepressants, followed by anticonvulsants, opioids, and other drugs. If all standard pharmacologic treatments fail, treatment of psychological problems induced by chronic pain is necessary since depression and the risk of suicide are significant in patients with poorly controlled CP.