Musculoskeletal pain, most frequently affecting the back and hips [6], is the most common cause of pain in people with stroke, reflecting partly its frequency in the general population, particularly in older people who are at higher risk of stroke. It may pre-date the stroke and may be particularly troublesome following stroke, when it may be exacerbated by immobility or impaired movement.

This is the most common cause of pain occurring following stroke and may occur immediately following stroke or develop over time. It is more common in people with weakness of the upper limb [7]. It may be present at rest but may more commonly be associated with movement, particularly shoulder abduction or rotation. It may be associated with shoulder subluxation and/or spasticity of the upper limb, but shoulder subluxation is not always associated with pain. It is sometimes associated with ipsilateral sensory loss.

CPSP is characterised by its unpleasantness and is often described as being unlike any pain experienced previously. Patients may describe it as unpleasant burning, numbness, or coldness and use bizarre descriptors such as ‘clawing my arm from the inside’ or ‘a red-hot poker in my muscles’ [8]. The intensity of pain can be exacerbated by stress or cold and alleviated by warmth or distraction. Pain is very burdensome, even when of low intensity, [9] interferes with sleep, [10] and impacts significantly on quality of life. It is often associated with allodynia (defined as pain that is evoked by a stimulus that is not normally painful; e.g., brushing or light touching) and dysaesthesia (an unpleasant abnormal sensation that may occur with or without a physical stimulus) [11]. Patients may describe pain or unpleasant sensations associated with light touch from clothing or bed clothes, from cold, or occurring spontaneously. This description of CPSP is not unique to stroke and is common to other types of central deafferentation pain, including those caused by demyelination, syringomyelia, and traumatic brain injury.

This is a severe neuropathic type of pain occurring at an extremity in association with vascular/autonomic changes that may initially be associated with hyperaemia but subsequently may be associated with reduced blood flow and atrophic changes. Although this is well described in textbooks, in the authors’ experience it is rare in association with stroke. Early mobilisation in patients with stroke may explain why this is now rarely seen.

Headache following all types of stroke is common but is particularly associated with some stroke syndromes at onset, particularly subarachnoid or intracerebral haemorrhage, cervical artery dissection, migraine-associated stroke, and cortical venous sinus thrombosis [12, 13].

As described in Chap.​ 10, spasticity is a common complication of upper motor neuron lesions such as stroke, and even with best practice physiotherapy may be a troublesome complication, causing limitation of movement, functional impairment, or pain. In one longitudinal study of people with first-ever stroke and upper limb weakness, almost half of the patients assessed developed some degree of spasticity in the first year [14].

Many people with stroke have pre-morbid musculoskeletal pain that is exacerbated by stiffness and immobility. Careful clinical assessment, together with optimisation of moving and handling techniques to avoid pain, are essential. Simple analgesia taken regularly is helpful.

Post-stroke shoulder pain can be extremely troublesome. It is made worse by movement of the shoulder, particularly abduction or rotation, and so impacts on activities of daily living such as washing and dressing and rehabilitation. There is little evidence that shoulder strapping or wheelchair attachments (to support the upper limb) prevent subluxation, reduce pain, or improve function [15] although these may be used to make it clear to carers that the shoulder is at risk of damage from incorrect handling or positioning. Many people find supporting the affected arm on a pillow while sitting makes it more comfortable. There is insufficient evidence to support electrical stimulation for regional shoulder pain, [16] although it may prevent post-stroke shoulder subluxation [17]. Although subacromial injection of corticosteroids has been used clinically and anecdotally may provide rapid relief, there is no good evidence to support its use [18]. Simple analgesia should be offered regularly.

The evidence for efficacy of drug therapy in CPSP is based on quite small numbers of clinical trials, some of which were on mixed neuropathic pain syndromes. Current practice is therefore based partly on specific trial evidence on CPSP and partly on management of other causes of neuropathic pain. There is specific controlled trial evidence for efficacy of amitriptyline, [19] pregabalin, gabapentin, [20] and opioids [21] in central neuropathic pain, although generally opioids are not used as first-line management because of the potential side effects, particularly constipation.