The goal of pain management is to improve function—enabling individuals to work, attend school, and participate in daily activities. The many treatment options will vary depending on the type of pain, its duration, and patient access.
The best way to prevent, assess, and treat people who experience chronic pain is the biopsychosocial treatment model. This model allows patients, healthcare providers, and caregivers to view pain as a dynamic interaction among and within the biological, psychological, and social factors unique to that individual. It provides the best foundation for tailoring the most comprehensive pain management program for each person.
Interdisciplinary treatment—which involves team members from different healthcare specialties working collaboratively to set goals, make decisions, and share resources and responsibilities—is based on the biopsychological model that is important when assisting chronic pain sufferers.
For the most part, the medications, procedures, interventions, and therapies listed below have been shown in clinical trials to help relieve or manage pain associated with a specific condition(s), but none have been proven fully effective in relieving all types of pain. Discuss with your healthcare provider which treatment, or combination of treatments, will be most effective for you and your pain condition. It is important to remember that, while not all pain is curable, all pain can be treated. Common treatments include:
Acupuncture involves the application of needles to precise points on the body to relieve pain. It is part of a category of healing called traditional Chinese medicine. Evidence of the effectiveness of acupuncture for pain relief is conflicting and clinical studies to investigate its benefits are ongoing.
Analgesic refers to the class of drugs that includes most “painkillers.” This includes classes of non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, ibuprofen, and naproxen, as well as acetaminophen and opioids (which have a narcotic effect and can induce sedation and pain relief). Nonprescription or over-the-counter pain relievers are generally used for mild to moderate pain. Prescription opioid pain relievers, sold through a pharmacy under the direction of a physician, are used for moderate to severe acute pain and are usually prescribed for short periods of time.
Anticonvulsants are used to treat seizure disorders because they dampen abnormally fast electrical impulses. They also are prescribed by physicians to treat various pain conditions, particularly neuropathic pain
Antidepressants are often used to treat chronic pain and are particularly used to help manage musculoskeletal pain, neuropathic pain, and headache-related pain.
Anti-inflammatory diets (nutrition) are another approach to chronic pain management. Research suggests that some people with chronic pain can benefit from eating anti-inflammatory foods to help reduce their level of pain with limited negative side effects.
Beta-blockers are medications which inhibit one arm of the sympathetic nervous system and adrenal “fight or flight” hormones. Propranolol and timolol are used to prevent migraine headaches.
Biofeedback is used to treat many common pain problems, most notably headache and back pain. Biofeedback enables individuals to learn how to change physiological activity for the purpose of improving health and performance. The biofeedback machine provides rapid and accurate feedback that helps people become aware of, follow, and gain control over certain bodily functions, including muscle tension, heart rate, breath rate, and skin temperature. Feedback in conjunction with changes in thinking, emotions, and behavior leads to physiological changes that can be sustained over time without continued use of the biofeedback machine. Biofeedback is often used in combination with other treatment methods, generally without side effects.
Botox(botulinum toxin) is a Food and Drug Administration (FDA)-approved treatment for chronic migraines—those that last for or occur for 15 or more days a month. Botox is injected around pain fibers that are involved in headaches. Botox enters the nerve endings and blocks the release of chemicals involved in pain transmission.
Calcitonin gene-related peptide (CGRP) monoclonal antibodies are a class of FDA-approved medications to help prevent frequent migraines. Some of the new medications include Aimovig, Ajovy, and Emgality.
Chiropractic care may ease back pain, neck pain, headaches, and musculoskeletal conditions. It involves "hands-on" therapy designed to adjust the relationship between the body's structure (mainly the spine) and its functioning. Chiropractic spinal manipulation includes the adjustment and manipulation of the joints and adjacent tissues. Such care also may involve therapeutic and rehabilitative exercises. A review of numerous clinical trials to assess the effectiveness of spinal manipulations concludes that there is only low-quality evidence of their benefit for acute and sub-acute low back pain. For chronic back pain however, there is evidence of small to moderate treatment relief.
Cognitive-behavioral therapy is a well-established treatment for pain that involves helping an individual improve coping skills—pacing day-to-day activities, addressing negative thoughts and emotions that can amplify pain, and learning relaxation methods to help prepare for and cope with pain and changes in the nervous system. It is used for chronic pain, postoperative pain, cancer pain, and with transitions from acute to chronic pain.
Counseling can give an individual pain sufferer much needed support, whether it comes from family, group, or individual counseling. Support groups can provide an important supplement to drug or surgical treatment. Psychological treatment also can help people learn how to better handle physiological changes produced by pain.
Electrical stimulation, including implanted electric nerve stimulation, and deep brain or spinal cord stimulation, is the modern-day version of age-old practices in which the nerves or muscles are stimulated by heat or massage. The following techniques require specialized equipment and trained personnel:
- TENS (transcutaneous electrical stimulation) uses tiny electrical pulses, delivered through the skin to nerve fibers, to cause changes in muscles, such as numbness or contractions. This in turn produces temporary pain relief. TENS can activate subsets of peripheral nerve fibers that can block pain transmission at the spinal cord level.
- Peripheral nerve stimulation uses electrodes placed surgically or percutaneously (injected through the skin) on a peripheral nerve. The individual is then able to send an electrical current as needed to the affected nerve, using a controllable electrical generator.
- Spinal cord stimulation uses electrodes surgically or percutaneously inserted between the spine's protective covering (the dura) and the spinal column. The individual can send a pulse of electricity to the spinal cord using an implanted electrical pulse generator that resembles a cardiac pacemaker.
- Deep brain stimulation is considered a more extreme treatment and involves surgical stimulation of the brain, usually the thalamus or motor cortex. It treats chronic pain in cases that do not respond or have stopped responding to less invasive or conservative treatments.
- Exercise also may be part of the pain treatment regime for most people with pain. A physician or physical therapist can recommend an appropriate routine. Participation in some form of exercise, physical activity, and stretching may help individuals with pain better manage their symptoms, handle daily activities, and maintain flexibility and muscle strength. Exercise, sleep, and relaxation can all help reduce stress, thereby helping to alleviate pain. Supervised exercise has been proven to help many people with low back pain.
Hypnosis, in general, is used to control physical function or response—that is, the amount of pain an individual can withstand. How hypnosis works is not fully understood, and there is limited research suggesting its effectiveness. Some believe that hypnosis enables individuals to improve their ability to concentrate and/or relax.
Injectionsare sometimes used to deliver pain relief medication locally.
- Facet injections target the facet joints (small stabilizing joints in the spine between and behind vertebrae). A person may get pain relief from the local anesthetic and may notice longer lasting relief starting two to five days after injection.
- Steroid injections work by decreasing inflammation and reducing the activity of the immune system. Injecting steroids into one or two local areas allows doctors to directly deliver a high dose of medication.
- Sacroiliac joint injection is used to diagnose the source of a person’s pain, as well as to provide therapeutic pain relief associated with sacroiliac joint dysfunction. The injection provides pain relief by reducing inflammation within the joint.
- Trigger point injections involve injecting a small amount of local anesthetic, sometimes with a steroid medication, directly into a painful trigger point (a specific site on the muscles that causes pain when pressed during an exam).
Low-power lasers have been used by some healthcare providers as a treatment for pain. This low intensity light therapy (not thermal) triggers biochemical changes within cells and may have an effect on pain, inflammation, and tissue repair, but this method is considered controversial.
Marijuana (cannabis) continues to remain highly controversial as a medical treatment to manage pain. Scientific studies are underway to test the safety and usefulness of cannabis for treating different medical conditions. Although marijuana has not been approved for any medical use at the federal level, several states and the District of Columbia permit the use of medical marijuana as a treatment.
- Marinol is an FDA-approved medication with the active ingredient dronabinol, a synthetic form of tetrahydrocannabinol (THC) used to treat chemotherapy-induced nausea and vomiting. Initial research has found that Marinol was no more effective than placebo for post-surgical and nerve-related pain, and only slightly more effective than placebo for chronic non-cancer pain.
Muscle relaxants are used to relax and reduce tension in muscles. Muscle relaxants are not a class of drugs, which means that they do not all have the same chemical structure or work the same way in the brain. The term “muscle relaxers” describes a group of drugs that act as central nervous system depressants and have sedative properties for musculoskeletal pain.
- Anxiolytics include medications in the class of benzodiazepines, used to decrease central nervous system activity. These drugs can act as muscle relaxants and are sometimes used to manage anxiety.
Nerve blocks use drugs, chemical agents, or surgical techniques to interrupt the relay of pain messages between specific areas of the body and the brain. Nerve blocks may involve local anesthesia, regional anesthesia or analgesia, or surgery, and are routinely used for traditional dental procedures. Nerve blocks also can be used to prevent or even diagnose pain and may involve injection of local anesthetics to numb the nerve and/or steroids to reduce inflammation.
A local nerve block may use one of several local anesthetics such as lidocaine or bupivacaine. Peripheral nerve blocks involve targeting a nerve or group of nerves that affect a part of the body. Nerve blocks also may take the form of what is commonly called an epidural, in which a drug is administered into the space between the dura and the spinal column. This procedure is best known for its use during childbirth. However, it is also used to treat acute or chronic leg or arm pain due to an irritated spinal nerve root.
- Neurolytic blocks employ injection of chemical agents such as alcohol, phenol, or glycerol, or the use of radiofrequency energy, to kill nerves responsible for transmitting nociceptive signals. Neurolytic blocks are most often used to treat cancer pain or pain in the cranial nerves.
- Sympathectomy, also called sympathetic blockade, typically involves injecting local anesthetic next to the sympathetic nervous system (involved with regulating heart rate, breathing, blood pressure, and response to stressful or dangerous situations). The procedure is often performed to treat neuropathic pain of a limb (e.g., complex regional pain syndrome) as well as vascular disease pain and other conditions.
- Surgical blocks are performed on cranial, peripheral, or sympathetic nerves. They are most often used to relieve cancer pain and extreme facial pain, such as that experienced with trigeminal neuralgia. There are several types of surgical nerve blocks and they are not without problems and complications. Nerve blocks can cause muscle paralysis and, in many cases, result in partial numbness. For that reason, the procedure should be reserved for a select group of individuals and should only be performed by skilled surgeons. Types of surgical nerve blocks include:
- Spinal dorsal rhizotomy, in which the surgeon cuts the root or rootlets of one or more of the nerves radiating from the spinal cord. Other rhizotomy procedures include cranial rhizotomy and trigeminal rhizotomy, performed as a treatment for extreme facial or cancer pain.
Physical therapy and rehabilitation may help to decrease pain and improve mobility. by increasing function, controlling pain, and aiding recovery. Individuals may engage in a number of physical therapy treatments simultaneously. A few of the most common forms (in addition to exercise, electrical stimulation, and ultrasound) are:
- Traction sometimes is used to decrease pain and improve mobility in the spine.
- Joint mobilization can occur when a physical therapist passively moves the joints of the body in specific directions to help decrease pain and improve mobility.
- Heat and ice are often used in physical therapy. Heat can increase circulation to the injured tissues, relax the muscles, and provide pain relief. Ice typically is used to help decrease pain and control inflammation.
- Kinesiology taping uses a flexible tape to support body parts and muscles to reduce bruising/swelling and provide pain relief.
Placebos are defined as substances without any therapeutic effect that are typically used as a control factor in clinical studies to determine the effectiveness of a medical treatment. Placebos are inactive substances, such as sugar pills, or harmless procedures such as saline injections, and may be prescribed more for the psychological benefit to the patient than for any physiological effect. Placebos, however, do offer some individuals pain relief. Although placebos have no direct effect on the underlying causes of pain, evidence from clinical studies suggests that many conditions such as migraine headache, back pain, post-surgical pain, rheumatoid arthritis, angina, and depression sometimes respond well to them. This is known as the placebo response, which is defined as the observable or measurable change that can occur after administration of a placebo. One significant component responsible for the effect of placebo is the degree to which people expect the treatment to work. Placebos work in part by stimulating the brain's own analgesics.
Relaxation and mindfulness are ways for people to respond to the physical sensation of pain, which can have a major impact on how the body’s nervous system creates and perceives pain. An individual’s automatic reactions to pain, often unconsciously, can amplify the pain-generating activity of the nervous system. Relaxation strategies (e.g., imagery, progressive muscle relaxation, autogenic relaxation) and mindfulness techniques (e.g., exercises that help the individual observe physical, cognitive, and emotional reactions and make skillful choices to relieve pain) are evidence-based practices to help shift the nervous system back toward a normal non-pain state.
R.I.C.E.—Rest, Ice, Compression, and Elevation—are four components prescribed by many orthopedists, coaches, trainers, nurses, and other professionals for temporary muscle or joint injuries, such as sprains or strains.
Radiofrequency ablation (RFA)uses an electrical current produced by a radio wave to heat up a small area of nerve tissue, thereby decreasing pain signals from that specific area. The degree of pain relief can vary depending on the cause and location of the pain. Some individuals can experience pain relief for up to 6-12 months.
Serotonergic agonists—the triptans (including sumatriptan, naratriptan, and zolmitriptan)—are used specifically for acute migraine headaches because they block pain pathways in the brain. Taken as pills, shots, or nasal sprays, they can relieve many symptoms of migraine.
Surgery may be recommended for some people with pain that significantly impacts their daily functioning. Surgery may be considered when less invasive treatments have not been helpful. However, surgical procedures are not always successful and may not be appropriate for all people.
Topical pain creams/gels are sprayed on or rubbed into the skin over painful muscles or joints. Although they are all designed to relieve pain, they have different ingredients. Topical pain creams and gels (e.g., compounded pain creams to treat specific pain) are sometimes prescribed by a physician, while others can be bought over the counter. There is limited evidence about the effectiveness of such creams. Below are the most common ingredients in products available without a prescription.
- Capsaicin (pronounced cap-SAY-sin) is a chemical found in chili peppers and is also a primary ingredient in prescription or over-the-counter pain-relieving creams as a treatment for several pain conditions, including shingles. This topical cream may be helpful for deep pain. It works by reducing the amount of substance P—a compound thought to be involved in the synaptic transmission of pain and other nerve impulses—that is found in nerve endings and interferes with the transmission of pain signals to the brain. Individuals can become desensitized to the compound, however, perhaps because of long-term capsaicin-induced damage to nerve tissue. Some people cannot tolerate the burning sensation they experience when using capsaicin cream.
- Counterirritants include ingredients such as menthol, methylsalycylate (oil of evergreen), and camphor. They are called counterirritants because they create a burning or cooling sensation that distracts the person from the pain.
- Salicylates are the same ingredients that give aspirin its pain-relieving quality and are found in some creams. When absorbed into the skin, they may help with pain, particularly in joints close to the skin, such as fingers, knees, and elbows.