Learn why some people develop chronic pain and others do not, and some methods that may help to mitigate it.
When Kim Mulholland was training for her first triathlon in the summer of 2021, she realized something wasn't right. Always fit, the now 54-year-old had attended Arizona State University on a full athletic scholarship for gymnastics and worked as a trauma yoga specialist near her home in Clyde, NC, so she was very in tune with her body. “I noticed that I kept tripping over my left foot like I was going to face-plant,” she says. “When I was riding my bike, I wouldn't necessarily notice where that foot was, or it would turn in a direction I hadn't intended.”
Doctors first theorized she had back problems or tarsal tunnel syndrome in her ankle, but after she experienced three focal seizures (jerking movements) in her left foot over one weekend, she underwent an MRI. The scan revealed a large meningioma, a benign tumor in the membranes surrounding the brain, that had grown to the size of a potato and invaded the entire right side of her brain, which was inflamed and swollen.
“I needed an emergency craniotomy [surgical removal of part of the skull to access the brain], and the neurosurgeon warned there was a possibility due to the size of the tumor that I could be paralyzed on my left side afterward and unable to speak,” Mulholland says. While she did wake up after the surgery unable to move her leg from the knee down, most of the paralysis began to resolve after 24 hours. But what remains to this day, after almost a year and a half of physical therapy, is weakness, constant pain, and spasticity in her leg.
“I can't move my left toes at all, my left ankle is limited in mobility and strength, and my left hip feels like it's being pulled by a rubber band all the time,” she says. “The pain is the hardest part. My foot goes from feeling ice-cold to burning hot. It also feels like I'm walking on rocks anytime I stand. Any material that touches my foot seems abrasive, like sandpaper. It's as if I always have two thick rubber bands wrapped tightly around my left foot with weights on them, and those symptoms never go away.”
A Confounding Problem
Mulholland's experience with chronic pain is distressingly common. According to a report from the U.S. Centers for Disease Control and Prevention (CDC), at least one in five American adults live with chronic pain, and for nearly a third of them, the chronic pain frequently limits their life or work activities.
People like Mulholland, who have survived a brain tumor or other injury to the brain (such as a stroke), may experience a condition known as central pain syndrome, caused by damage to the pain-conducting pathways in the central nervous system. For others, chronic pain can be linked to trauma or an overuse injury, migraine or stress headaches, multiple sclerosis, neuropathy, fibromyalgia, or arthritis. In many cases, these pain syndromes overlap. And low back pain that lasts for an extended period can develop into a more brain-centric pain syndrome.
“Often, people who live with chronic pain experience what we call central sensitization,” says Nathaniel M. Schuster, MD, associate clinic director at the UC San Diego Center for Pain Medicine. “When you sustain a tissue injury, for example, the pain signals are conducted by the peripheral nerve from the injured area through the central nervous system along the spinal cord up to the brain. Some people then experience a ‘peripheral sensitization,’ a strengthening of the connection between the nerves, where the nerves become hypersensitized. In essence, the nervous system learns to be more sensitive to pain.”
Researchers are trying to figure out why some people develop central sensitization or chronic pain after an injury or illness while others do not. “This is a huge area of pain research and one that we know the least about, unfortunately,” says Gregory Corder, MD, assistant professor of psychiatry at the University of Pennsylvania. In his lab, Dr. Corder studies how the brain generates the perception of pain.
“Pain is deeply personal and individual, but it does seem that people who are predisposed to certain types of psychiatric disorders, such as depression and anxiety, are at higher risk of transitioning from acute to chronic pain,” he says. “Things like lifestyle—how sedentary you are versus how active you are—as well as your nutrition and sleep health also appear to be factors in whether or not you develop chronic pain.”
Genetic causes and inherited factors can predispose people to develop chronic pain as well. A major area of Dr. Corder's research focuses on the mu opioid receptor, a type of protein involved in how we perceive and respond to pain. “The body's natural painkillers—like endorphins—which are released in times of stress, pain, or injury, bind to those same receptors,” he explains. “If there are changes in this receptor gene, it can't signal or function properly, so the body lacks an ability to regulate pain. This is one example, among others, of a potential genetic cause of chronic pain.”
Preventing the transition from acute pain to chronic pain is key, says Gary Franklin, MD, FAAN, a research professor in neurology and environmental sciences at the University of Washington in Seattle. “Developing chronic pain after three months is essentially the same as developing a disability.”
In a landmark study conducted in the early 2000s, Dr. Franklin and colleagues studied nearly 4,000 people with either low back pain or carpal tunnel syndrome, tracking them over a year from their acute injury to assess what factors might predict who became disabled with chronic pain and who did not.
“We found that the physical elements of pain are influenced by psychological factors—thoughts, emotions, and behaviors—as well as social circumstances,” he says. He and his group developed a short questionnaire for people recovering from an injury that asks how much they expect pain to interfere with their ability to work and whether they're concerned about work exacerbating the pain. “If someone takes this questionnaire shortly after an injury, it's highly predictive of what will happen later and whether the pain will become chronic,” says Dr. Franklin.
People who believe pain will prevent them from returning to work or that work will make it worse—a phenomenon known as “catastrophizing”—are more likely to develop chronic pain, he says, adding: “Evidence shows that cognitive behavioral therapy can help overcome those barriers to recovery.”
Pain medications themselves sometimes make pain worse. Studies comparing people's pain sensitivity before and after opioid therapy, as well as the pain sensitivity of people who have taken opioids for a long time, found that exposure to opioids increased sensitivity to pain and made preexisting pain worse. The higher the opioid dose, the higher the sensitivity to pain, according to the studies. “Known as opioid-induced hyperalgesia, it's unclear how common it is,” says Dr. Schuster.
Medication Overuse Headaches
Overusing headache medication can contribute to episodic migraine becoming chronic. Jennifer Nierenberg Metzger, 52, an attorney in Montclair, NJ, had been “prone to headaches” from childhood—even taking a suitcase full of Advil to summer camp—but during her first pregnancy in 2006, the migraines became more frequent, as many as 25 a month. Her pain intensified after a doctor gave her prescriptions for sumatriptan (Imitrex) and Fioricet—a combination of acetaminophen, a barbiturate called butalbital, and caffeine—and suggested she medicate liberally and frequently.
“At one point I was taking Imitrex almost daily and Fioricet at least twice a week, and my headaches started getting worse both in severity and frequency,” she says. “I couldn't get out of the cycle. Every time I went back to the doctor, I kept getting more and different medications.”
When she moved to New Jersey from Massachusetts in 2008, her new neurologist explained the phenomenon of medication overuse headaches—recurring migraines caused by long-term use of headache medication—and prescribed a three-week medication detox. “It was probably the most hellacious three weeks of my life,” she says. “Since then, I'm very judicious about the medications I take. I don't want to say medication overuse headaches are more intense than a bad migraine, but they're close and they don't go away.”
As of 2017, the U.S. Food and Drug Administration has required that certain over-the-counter medications, including naproxen (Aleve), come with a warning that if used 10 or more days a month, headaches may worsen. Research suggests that taking certain pain relievers—including opioids, triptans, and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and aspirin—so frequently can alter the brain's serotonin system and lead to increased pain sensitivity.
It Takes a Village
“Medication alone is not the answer,” says Dr. Schuster. “Pain management is individualized to the patient and may involve a combination of cognitive behavioral therapy (CBT), physical therapy, mindfulness meditation, and progressive muscle relaxation, as well as possibly neuromodulation tools such as spinal cord and peripheral nerve stimulators.”
“Multidisciplinary approaches to pain, whether it's chronic due to an injury or from a neurologic condition, are always better,” agrees Dr. Franklin. Those approaches may include medication, exercise, physical therapy, psychological counseling, massage, mindfulness, and biofeedback. Pain reprocessing therapy (PRT)—which uses techniques drawn from pain neuroscience education, CBT, and mindfulness-based stress reduction to help patients reframe chronic pain as a brain-generated false alarm—showed promising results in a randomized controlled trial published in JAMA Psychiatry in 2022.
Dr. Franklin recommends the progressive goal attainment program (PGAP)—developed by Michael Sullivan, PhD, professor of psychology, medicine, and neurology at McGill University in Montreal—to reduce disability associated with pain, depression, posttraumatic stress disorder, cancer, and other chronic health conditions. PGAP helps people get back to their usual activities through exercise and CBT, “two of the most effective treatments for preventing and treating chronic pain,” Dr. Franklin says.
Managing pain requires a team including doctors, physical therapists, and psychologists or social workers, says Dr. Schuster. “Patients who believe in themselves and want to partner with that team very often do better than those seeking doctors who are going to cure them,” he says.
“Make sure you have investigated the possible underlying causes as well,” says Jennifer W. McVige, MD, director of the Concussion Center at the Dent Neurologic Institute in Amherst, NY, and a specialist in adult and pediatric headache. She's had patients with peripheral neuropathy whose pain eased significantly when their vitamin B12 deficiency was discovered and treated. “Go back to basics: Are your iron levels okay? Is your liver function okay? Once you've ensured that everything has been appropriately evaluated, managing chronic pain becomes a mind-body proposition.”
Understanding your pain is hugely empowering, says Dr. McVige. “It's tempting to want to take a pill to make it all go away, but that's not how pain management works. Sometimes you have to do multiple things simultaneously to make yourself well, including taking care of your mental health and nurturing a strong support system. It's okay to invest time in being kind to yourself.”
Multidisciplinary Treatment Approach
Over the past 17 years, Jennifer Nierenberg Metzger has tried almost every migraine treatment available, from acupuncture, Botox, biofeedback, and massage to newer preventive treatments such as the injectable drug fremanezumab (Ajovy) and the electrical nerve stimulation device Cefaly, both of which helped her.
