The Budapest criteria diagnose complex regional pain syndrome (CRPS) on four conditions: continuing, disproportionate pain, reported symptoms, signs observed on examination, and no other diagnosis that better explains the presentation. In their validation sample, the clinical set keeps a sensitivity of 0.99 and raises specificity from 0.41, that of the 1994 criteria, to 0.68. The checker is right below.

The clinical set has a sensitivity of 0.99 and a specificity of 0.68; the research set, 0.78 and 0.79. It gains little specificity and loses a lot of sensitivity. The detail is below.

Figures taken from the studies listed at the end of this page, every value carrying its source where it is written. The statement of the criteria follows the appendix of the 2010 validation paper and the table of the 2021 Valencia consensus, reworded.

What the Budapest criteria decide

The Budapest criteria answer a single question: is this presentation a complex regional pain syndrome? They return a decision, yes or no, not a score. Proposed by an international consensus group that met in Budapest, they were validated by Harden et al. in 2010 in 113 patients with type I CRPS and 47 patients with neuropathic pain of other origin, across seven centres.

They replace the 1994 IASP criteria, which had brought together under the name CRPS reflex sympathetic dystrophy, which became type I, without an identifiable nerve lesion, and causalgia, which became type II, with a defined nerve lesion. The 1994 criteria came from consensus, not validation, and they overdiagnosed: in the 2010 sample, their specificity is only 0.41.

Their split into four categories comes from data. A 1999 statistical analysis, in 123 patients, had separated a vasomotor factor from a sudomotor and oedema factor, which the 1994 criteria merged, and isolated a motor and trophic factor they ignored.

The statement of the four conditions

All four conditions are required. A: continuing pain, disproportionate to any inciting event. B: at least one symptom reported by the patient in at least three of the four categories. C: at least one sign observed by the examiner, at the time of evaluation, in at least two categories. D: no other diagnosis better explains the signs and symptoms.

• Sensory: reported hyperaesthesia or allodynia; on examination, hyperalgesia to pinprick, or allodynia to light touch, deep somatic pressure or joint movement.
• Vasomotor: temperature asymmetry, skin colour change or asymmetry, reported or observed.
• Sudomotor and oedema: oedema, sweating change or asymmetry, reported or observed.
• Motor and trophic: decreased range of motion, motor dysfunction (weakness, tremor, dystonia) or trophic change (hair, nails, skin), reported or observed.

The research set changes only one thing: it requires a symptom in all four categories instead of three. Signs stay at two categories in both sets.

The Valencia consensus, held in 2019 and published in 2021, clarifies how to examine without touching the wording of the criteria. Hyperalgesia is tested with a pinprick, compared with the healthy side; allodynia is confirmed by a single positive stimulus, among light touch, light skin pressure, a tuning fork or temperature; asymmetries are judged against the opposite limb. Its table merges the sensory lists of both columns into one, which adds temperature sensation, absent from the 2010 appendix.

Two more recent sources differ on one word. On the symptom side, the 2010 appendix and the Valencia table write hyperaesthesia, keeping hyperalgesia for signs; the 2022 guidelines and the table of the self-report version of the severity score write hyperalgesia on the symptom side too. This page follows the text of the validated criteria.

Two sets, a trade-off that does not go the expected way

The research set exists to gain specificity at the cost of sensitivity. In the validation sample, the gain is modest and the cost high: specificity rises from 0.68 to 0.79, and sensitivity falls from 0.99 to 0.78.

The consequence shows in the negative predictive value. At a CRPS prevalence of 70 %, it is 0.97 for the clinical set and 0.60 for the research set: a negative result from the research set no longer rules out much. The authors themselves conclude that its advantage over the clinical set was minimal, and that two separate sets might not be needed.

In practice, the clinical set is the one for diagnosis. The research set remains, by custom, the one for clinical trials.

What the criteria do not tell you

They say nothing certain about type II. The validation study excluded it from its main analysis, for lack of numbers: 13 % of the initial cohort. The sensitivity and specificity figures are therefore shown only for telling type I apart from neuropathic pain. The Valencia consensus nevertheless recalls that the signs of both types are identical, and that for type II they must extend beyond the territory of the injured nerve to count.

They do not measure severity. The number of signs and symptoms present separates the groups well, 12.0 on average in CRPS against 5.4 in the other patients, but the decision stays binary. A continuous score adding up the four categories would do better on paper, with a sensitivity of 0.95 and a specificity of 0.81, and the authors warn that it does not compare with the threshold a clinician actually has to set.

They do not describe the course. Over time, the categories involved shift: more sensory signs and symptoms, fewer vasomotor ones, and a gradual move from a warm to a cold presentation.

Three pitfalls in applying them

Counting a sign as a symptom

An examiner may observe a colour or temperature asymmetry the patient has not reported, because they do not perceive it. The Valencia consensus is explicit: the observed sign does not automatically count as the corresponding symptom. A patient can thus miss the threshold of three symptom categories while having enough objective signs.

Examining only once

Signs and symptoms fluctuate. Valencia recommends going through the whole list of symptoms at every formal evaluation, including those the patient had not reported so far.

Treating criterion D as a formality

The absence of another diagnosis is a condition in its own right. In a Belgian cohort of 24 patients who all met the Budapest criteria in the upper limb, carpal tunnel-targeted treatment for an irritative carpal tunnel brought pain down from 70 to 11 out of 100 in the 18 patients with complete follow-up.

Frequently asked questions

What are the Budapest criteria?

They are the diagnostic criteria for complex regional pain syndrome, validated in 2010. They require four conditions: continuing, disproportionate pain, symptoms reported in at least three of four categories, signs observed in at least two, and no other diagnosis that better explains the presentation.

What is the difference between the clinical and the research criteria?

Only one: the research set requires a symptom in all four categories instead of three. In the validation sample, it gains little specificity, 0.79 against 0.68, and loses a lot of sensitivity, 0.78 against 0.99.

Is there a Budapest score?

The criteria give no score, they return a decision. The severity score derived from them, the CRPS Severity Score, runs from 0 to 16: 8 signs and 8 symptoms coded present or absent. A change of at least 4.9 points signals a real change.

Is there a questionnaire for CRPS?

The diagnosis is not made by questionnaire, since signs are observed on examination. A self-report version of the severity score exists for remote screening, with a cut-off of 8 of 16, but its authors reserve it for recruiting into clinical trials.

Do the Budapest criteria apply to type II CRPS?

The signs are the same, and for type II they must extend beyond the territory of the injured nerve. But the validation study excluded type II for lack of numbers: its sensitivity and specificity are shown only for type I.

References

11 sources, PMIDs included

1. Stanton-Hicks M, Janig W, Hassenbusch S, Haddox JD, Boas R, Wilson P. Reflex sympathetic dystrophy: changing concepts and taxonomy. Pain 1995;63(1):127-33. PMID 8577483. The 1994 IASP taxonomy. It brings reflex sympathetic dystrophy and causalgia together under the single name CRPS, in two types: type I without an identifiable nerve lesion, type II with a defined nerve lesion. It is the text the Budapest criteria revised.
2. Bruehl S, Harden RN, Galer BS, Saltz S, Bertram M, Backonja M, Gayles R, Rudin N, Bhugra MK, Stanton-Hicks M. External validation of IASP diagnostic criteria for Complex Regional Pain Syndrome and proposed research diagnostic criteria. Pain 1999;81(1-2):147-54. PMID 10353502. The external validation of the 1994 criteria, in 117 patients meeting them and 43 neuropathic pain patients of other origin. Sensitivity of 0.98, specificity of 0.36: a positive diagnosis was correct in as few as 40 % of cases, hence the revision.
3. Harden RN, Bruehl S, Galer BS, Saltz S, Bertram M, Backonja M, Gayles R, Rudin N, Bhugra MK, Stanton-Hicks M. Complex regional pain syndrome: are the IASP diagnostic criteria valid and sufficiently comprehensive? Pain 1999;83(2):211-9. PMID 10534592. The statistical analysis that founded the four categories, in 123 patients: a vasomotor factor distinct from a sudomotor and oedema factor, which the 1994 criteria merged, and a motor and trophic factor they ignored.
4. Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med 2007;8(4):326-31. PMID 17610454. The paper announcing the criteria from the Budapest consensus: data-derived revisions, because the 1994 criteria were sensitive but poorly specific, and ignored motor and trophic signs.
5. Harden NR, Bruehl S, Perez RSGM, Birklein F, Marinus J, Maihofner C, Lubenow T, Buvanendran A, Mackey S, Graciosa J, Mogilevski M, Ramsden C, Chont M, Vatine JJ. Validation of proposed diagnostic criteria (the "Budapest Criteria") for Complex Regional Pain Syndrome. Pain 2010;150(2):268-74. PMID 20493633. The validation study, in 113 type I CRPS and 47 neuropathic pain patients, across seven centres. 1994 criteria: sensitivity 1.00, specificity 0.41. Budapest, clinical set: 0.99 and 0.68. Research set: 0.78 and 0.79. Type II CRPS, 13 % of the cohort, is excluded from the main analysis. The appendix states the criteria in full.
6. Harden NR, Bruehl S, Perez RSGM, Birklein F, Marinus J, Maihofner C, Lubenow T, Buvanendran A, Mackey S, Graciosa J, Mogilevski M, Ramsden C, Schlereth T, Chont M, Vatine JJ. Development of a severity score for CRPS. Pain 2010;151(3):870-6. PMID 20965657. The construction of the CRPS Severity Score, in 114 CRPS and 41 neuropathic pain patients, from 17 signs and symptoms. The score separates the two groups and tracks pain intensity, distress and functional limitation.
7. Harden RN, Maihofner C, Abousaad E, Vatine JJ, Kirsling A, Perez RSGM, Kuroda M, Brunner F, Stanton-Hicks M, Marinus J, van Hilten JJ, Mackey S, Birklein F, Schlereth T, Mailis-Gagnon A, Graciosa J, Connoly SB, Dayanim D, Massey M, Frank H, Livshitz A, Bruehl S. A prospective, multisite, international validation of the Complex Regional Pain Syndrome Severity Score. Pain 2017;158(8):1430-6. PMID 28715350. The prospective validation of the score, in 156 patients: a change of at least 4.9 points signals a real difference in symptoms, with 95 % confidence.
8. Goebel A, Birklein F, Brunner F, Clark JD, Gierthmuhlen J, Harden N, Huygen F, Knudsen L, McCabe C, Lewis J, Maihofner C, Magerl W, Moseley GL, Terkelsen A, Thomassen I, Bruehl S. The Valencia consensus-based adaptation of the IASP complex regional pain syndrome diagnostic criteria. Pain 2021;162(9):2346-8. PMID 33729210. The Valencia consensus, held in 2019. It clarifies the examination without changing the wording of the criteria, creates the subtype CRPS with remission of some features, and recalls that an observed sign does not count as the corresponding symptom.
9. Harden RN, McCabe CS, Goebel A, Massey M, Suvar T, Grieve S, Bruehl S. Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition. Pain Med 2022;23(Suppl 1):S1-S53. PMID 35687369. The practical guidelines, 5th edition. They give the final version of the CRPS Severity Score: 16 elements, 8 signs and 8 symptoms coded present or absent, for a score of 0 to 16.
10. Bruehl S, Sideris A, Chen T, Gungor S, Horine S, Kramskiy V, Billings FT, Anderson S, Harden RN. Validation of a self-report measure for diagnostic screening and assessment in complex regional pain syndrome. Pain Rep 2026;11(3):e1410. PMID 41958857. The self-report version of the score, for remote screening. Cut-off at 8 of 16: sensitivity and specificity of 0.79 for predicting a Budapest diagnosis, in 80 patients from a pain clinic. A recruitment tool, not a diagnostic one.
11. Lavigogne C, Cromheecke M, De Keyzer PB, Coeman P, Goubau J. Carpal tunnel-targeted treatment in patients with CRPS-like symptoms: a retrospective cohort study of irritative carpal tunnel syndrome. Hand Surg Rehabil 2026:102715. PMID 42379301. A Belgian cohort of 24 patients who all met the Budapest criteria in the upper limb, with an irritative carpal tunnel. After carpal tunnel-targeted treatment, pain falls from 70 to 11 out of 100 in the 18 patients with complete follow-up: criterion D is not a formality.