there is growing evidence supporting the role of central dopaminergic neurotransmission in modulating pain perception , although the exact mechanisms by which dopamine influences pain processing remain to be determined . several novel classes of medication with analgesic properties have bearing on dopaminergic activity as evident in the capacity of dopamine antagonists to attenuate their analgesic capacity . activation of mesolimbic dopamine neurons , arising from the cell bodies of the ventral tegmental area and projecting to the nucleus accumbens , plays an important role in mediating the suppression of tonic pain . this plausibly explains the role of pramipexole , a dopamine agonist with 7- to 10-fold higher affinity for d3 receptor subtypes than for either d2 or d4 receptors , in reducing pain . treatment with pramipexole in clinical conditions such as restless legs syndrome , fibromyalgia , and parkinsonism has been found to significantly improve measures of pain along with the other symptoms . there is no research data available that looks into the usefulness of pramipexole in somatoform / functional pain syndromes . here , we report a single case of bilateral functional shoulder pain associated with insomnia and zolpidem dependence achieving remission with pramipexole monotherapy . a 65-year - old male presented with history of taking 70 - 80 mg zolpidem / day in 6 - 8 divided doses . one year back , the patient had an insidious onset of pain in both shoulders for which he had consulted an orthopedic surgeon . he also complained of difficulty in initiating and maintaining sleep , attributing it to be secondary to the shoulder pain . investigations were done that included complete blood counts ; renal , hepatic and thyroid function tests ; fasting and postprandial blood sugar ; vitamin b12 and d3 assay ; serum uric acid , all of which were within the normal range . analgesics , including nonsteroidal antiinflammatory drugs and oral opioids ( tramadol ) reduced the pain only by 10% as reported by the patient . the patient was diagnosed as having pain disorder and was prescribed 40 mg duloxetine in two divided doses and 10 mg zolpidem hs . he discontinued duloxetine in 5 days of starting due to excessive nausea experienced each time after taking duloxetine , but continued zolpidem . since , he also felt relieved of the shoulder pain with zolpidem apart from improved sleep ; he started taking it in the daytime . he remained virtually free of pain for 1 - 2 h after taking zolpidem , following which the pain would gradually reappear . he increased the frequency of zolpidem intake to once every 2 - 3 h so that for the last 6 months , he took 7 - 8 tablets of 10 mg zolpidem in a day . on not taking zolpidem for 4 - 5 h , he felt anxious , diaphoretic , restless , and tremulous , agitated and had a resurgence of intense shoulder pain ; all of these would subside after taking zolpidem . a physician evaluation affirmed the absence of any significant current medical illness . at the time of presentation , the patient was diagnosed as having zolpidem dependence and was treated as an inpatient . pregabalin was started at a dose of 75 mg hs , which was discontinued in 2 days as the patient had intolerable giddiness on it . quetiapine 50 mg hs was then started , which also had to be discontinued as it caused physical weakness and lethargy in excess of the patient 's tolerability . thereafter , he was put on pramipexole sustained release ( sr ) preparation 0.26 mg hs for 5 days . as there was favorable response in the form of reduction in the intensity of pain and no adverse effects reported , the dose was increased to 1.05 mg of pramipexole sr . on follow - up for the next 6 months , the patient was maintained on the same dose of pramipexole . he no longer complained of pain or insomnia and reported of being abstinent from zolpidem . zolpidem , a nonbenzodiazepine hypnotic has higher abuse and dependence potiential than previously documented , and our case adds to the existing literature . based upon previous reports , we initially tried detoxification with pregabalin and quetiapine , but were unsuccessful due to tolerability issues . since , the patient had co morbid pain disorder and insomnia , pramipexole was started for its putative role in pain control as well as in improving sleep . involvement of central nervous system in the form of autonomic nervous system dysregulation has been implicated in the pathophysiology of functional pain syndromes . adrenergic arousal arising from the locus ceruleus ( central sympathetic stimulation ) alters nociception and fragments deep sleep . this may enable pramipexole , a d3 receptor agonist to reduce pain and restore sleep by augmenting the mesolimbic control of excessive adrenergic arousal . pain syndromes such as migraine and burning mouth syndrome have been reported to improve with pramipexole . besides , pramipexole improves sleep in patients with parkinsonism and restless legs syndrome as well as is effective in treating rapid eye movement sleep behavior disorder and sleep related eating disorder , suggesting its possible role in restoration of normal sleep . since this is a single case report , we do not exclude the possibility of the beneficial effect of pramipexole in our patient to be either placebo or coincidental . placebo - controlled blinded studies are needed to establish the effectiveness of pramipexole in functional pain syndromes and associated insomnia .
pramipexole is a dopamine agonist with higher affinity for d3 receptors . 
 treatment with pramipexole in clinical conditions such as restless legs syndrome , fibromyalgia , and parkinsonism has been found to significantly improve measures of pain and sleep along with the other symptoms . 
 there is no research data available that explores the usefulness of pramipexole in somatoform / functional pain syndromes . 
 we report a case of a 65-year - old male with bilateral functional shoulder pain associated with insomnia and zolpidem dependence effectively treated with pramipexole .