Chronic pain is one of the conditions I find most challenging to discuss with patients — not because the science is unclear, but because what the science says is so different from what most people expect and want to hear.
They expect a diagnosis. A cause. A fix. An operation, an injection, a medication that will make the pain go away.
What the evidence tells us is that for most chronic pain conditions, the most effective treatments are psychological and behavioural rather than medical or surgical. That scans and tests often make things worse, not better. That opioid painkillers — the most powerful pain medications we have — are frequently ineffective for chronic pain and create serious new problems.
This is not what people want to hear. It is also the truth, and you deserve to hear it.
Why chronic pain is not simply "more acute pain"
When acute pain persists, something happens in the nervous system called central sensitisation. The pain-processing pathways become hypersensitive — amplifying signals, responding to stimuli that would not normally cause pain, and maintaining pain signals even after the original tissue injury has healed.
In chronic pain, the volume knob of the pain system has been turned up. The pain is real — it is not imagined or exaggerated. But it is no longer reliably correlated with tissue damage.
This explains several confusing features of chronic pain:
- Why people have severe pain without any findings on imaging
- Why pain can spread beyond the original injury site
- Why stress, poor sleep, and low mood make pain significantly worse
- Why purely physical treatments often fail
- Why psychological approaches can meaningfully reduce pain
Common chronic pain conditions
Fibromyalgia: Widespread musculoskeletal pain affecting multiple body areas, accompanied by fatigue, sleep disturbance, and cognitive difficulties ("fibro fog"). Affects approximately 2–4% of the population, predominantly women. No structural cause identified on imaging. Strongly associated with central sensitisation. Often dismissed or labelled psychosomatic — it is neither. It is a real, recognised condition with specific diagnostic criteria and evidence-based treatment.
Chronic low back pain: After 12 weeks, back pain transitions from acute to chronic. Central sensitisation often plays a significant role. Imaging findings are usually unhelpful and often misleading. See our dedicated back pain guide.
Chronic headache/migraine: When headaches occur on 15 or more days per month. Can include medication overuse headache (rebound headache from taking too much pain medication — a genuinely vicious cycle).
Chronic pelvic pain: Affects both men and women. Can be associated with conditions including endometriosis, IBS, and interstitial cystitis — but also exists independently of identifiable structural causes.
Neuropathic pain: Pain from damaged or dysfunctional nerves — burning, shooting, or electric shock sensations. Causes include diabetes (diabetic neuropathy), shingles (postherpetic neuralgia), chemotherapy, and nerve compression.
Case study: Blessing's fibromyalgia diagnosis
Blessing, 44, had been experiencing widespread pain for three years before she came to see me. She had seen multiple specialists — rheumatology, orthopaedics, neurology. Multiple blood tests, two MRIs, and an EMG. All normal. She had been told variously that she was depressed, that it was "stress," and — most damagingly — that there was nothing physically wrong with her.
She was in significant pain. She had stopped working. She had gained weight from inactivity. She was sleeping 11 hours and waking unrefreshed. Her concentration had deteriorated to the point where she struggled to read a paragraph.
I diagnosed fibromyalgia using the 2016 ACR diagnostic criteria — widespread pain index and symptom severity scale. I explained what fibromyalgia is. I explained central sensitisation. I explained that "nothing wrong" on imaging does not mean "nothing wrong."
"I cried," she told me. "Not because it was bad news. Because it finally had a name."
We discussed the evidence-based treatment plan: graded exercise therapy, CBT for pain, sleep hygiene, and low-dose amitriptyline for sleep. We discussed what would not help: opioids, repeated investigations, waiting for a "cure."
Eighteen months later: working part-time, walking 30 minutes daily, pain scores reduced from 8/10 to 4/10. Not cured — fibromyalgia rarely is. But meaningfully better and functional.
What actually helps — the evidence
Exercise: The most evidence-supported intervention for most chronic pain conditions. Aerobic exercise, resistance training, and specific condition-appropriate movement (yoga, hydrotherapy) all have evidence. The mechanism is complex — exercise modulates central sensitisation, improves mood, reduces inflammation, and improves sleep. Start gradually and increase progressively.
Cognitive Behavioural Therapy for Pain (CBT-pain): Addresses the thoughts and behaviours that maintain and amplify pain — catastrophising ("this pain will never end"), fear-avoidance behaviour (avoiding all activity for fear of making pain worse), and the emotional responses to pain. Evidence consistently shows CBT-pain reduces pain intensity and improves function.
Pain Management Programmes (PMPs): Intensive multidisciplinary programmes combining physiotherapy, psychology, and education. The most comprehensive evidence-based intervention for complex chronic pain. Ask your GP for a referral.
Mindfulness-Based Stress Reduction (MBSR): Teaches present-moment awareness of pain without catastrophising. Significant evidence for reducing pain interference with daily life.
Sleep: Chronically poor sleep amplifies pain. Addressing sleep disturbance — through CBT-I (see our sleep article) or medication where appropriate — reliably reduces pain.
Antidepressants: Low-dose amitriptyline (not primarily for depression but for its pain-modulating effects) is evidence-based for fibromyalgia, neuropathic pain, and chronic headache. SNRIs (duloxetine) have good evidence for diabetic neuropathy and fibromyalgia.
Anticonvulsants: Pregabalin and gabapentin are licensed for neuropathic pain and fibromyalgia. Significant misuse potential — prescribed carefully.
What does not help — or actively makes things worse
Opioids for non-cancer chronic pain: Strong opioids (morphine, oxycodone, fentanyl) are poorly effective for most chronic non-cancer pain — clinical trials show minimal benefit over placebo at 3 months. They cause tolerance (requiring escalating doses), physical dependence, hormonal effects, immune suppression, and — at high doses — paradoxical opioid-induced hyperalgesia (the opioids actually increase pain sensitivity). The UK is experiencing an opioid prescribing crisis that mirrors the earlier US experience. If you are on long-term opioids for chronic pain with limited benefit, discuss a supervised reduction with your doctor.
Repeated imaging and investigations: Each new scan showing a "finding" shifts focus back to the tissue-damage model and away from the central sensitisation model that more accurately explains most chronic pain. This leads to more investigations, potentially unnecessary interventions, and entrenched pain behaviour.
Prolonged rest and avoidance: Fear-avoidance — avoiding all activities that might worsen pain — leads to deconditioning, loss of function, weight gain, depression, and ultimately more pain. Graded activity, guided by a physiotherapist, is almost always better than rest.
Sources: NICE Clinical Guideline CG173 — Neuropathic Pain in Adults (2013, updated 2023); NICE — Chronic Pain guideline NG193 (2021); Woolf CJ, PNAS 2011 (central sensitisation); Eccleston C et al, Cochrane Review — Psychological therapies for chronic pain 2014; Busse JW et al, JAMA 2018 (opioids for chronic non-cancer pain); Wolfe F et al, Arthritis Care & Research 2016 (fibromyalgia diagnostic criteria).
