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The different kinds of pain

There are three basic types of pain, depending upon what physical mechanism in the body is causing the symptom: somatic, neuropathic, and visceral. It's important to know what basic kind of pain is present, because treatment differs. Myofascial pain is a special kind of somatic pain with some interesting properties.

The most common physical type of pain is "somatic" pain, which means pain in the skin, bones, muscles, ligaments, tendons, and joints. This includes arthritis, tendonitis, and most kinds of headaches, neck pain, and low back pain. This kind of pain is typically aching, sore, and knifelike. It often improves when with aspirin or ibuprofen. Similar but sharper pain would occur if you cut or bruised yourself or broke a bone.

Acute somatic pain due to an injury or infection requires rest while the tissue heals. Chronic somatic pain usually does best with frequent gentle exercise that gradually intensifies as you become fit.

Less common is "neuropathic" pain, which is due to a disease or injury affecting the nervous system. It's like the burning, tingling, or electric feeling you get when you hit your "funny bone" (ulnar nerve) in your elbow. It includes carpal tunnel syndrome, various kinds of pinched nerves, and "neuropathy" or nerve damage due to diabetes or a variety of other illnesses. Another common neuropathic pain is postherpetic neuralgia that follows "shingles," an outbreak of herpes zoster. Neuropathic pain usually responds poorly to anti-inflammatory agents like ibuprofen, but it often improves with Neurontin or another antiseizure medication. (These drugs prevent seizures by stabilizing the nervous system, and they appear to help pain the same way.) Opiates like morphine or Vicodin typically aren't helpful.

Neuropathic pain requires attention to the underlying cause of the pain, whether it be diabetes, shingles, or a pinched nerve. Often, once you've treated the underlying problem as best you can, frequent gentle exercise gradually reduces the pain.

With one exception, "visceral" pain is rarely chronic (long-lasting), but many people have brief periods of visceral pain when their stomachs are upset, or during a menstrual period. (The only common chronic visceral pain is irritable bowel syndrome.) Visceral pain is due to contractions in a hollow organ. Menstrual cramps and labor are visceral pain, as is pain from kidney stones and gallstones. It is a deep, crampy, boring sensation that ranges from mild to extremely severe. It often responds to the same medications as somatic pain, but exercise is not usually helpful.

Interestingly, all three kinds of pain often improve with antidepressant medication, whether or not the person with pain is depressed. Sometimes doctors prescribe antiseizure medications like Neurontin regardless of what type of pain you have. I don't think this works well for most somatic or visceral pain, and people may just get side effects (grogginess and difficulty concentrating) without benefit.

(Warning: someone who's been on a drug like Neurontin for more than a few days should not stop it suddenly, or they could develop convulsions.)

Myofascial pain

By far the most common type of pain is myofascial pain—achy and tender muscles. Common examples include tension headaches and the majority of neck, shoulder, and low back pain. It can be triggered by injury, illness, depression, anxiety, fear, insomnia, and stress. It's the pain you feel if you wake up with a "wry neck," an aching in your neck if you sleep wrong. If you have low back pain that comes and goes, suddenly producing painful spasms, this is probably myofascial as well. There is no actually pathology associated with myofascial pain: your muscles are tense and sore but not injured. Sometimes pain and spasm create a mutually reinforcing vicious cycle. Most patients are surprised at how intense myofascial pain can be, and how long it can last (years, although usually it improves on its own).

One contributing factor is that involved muscles are often bunched up and shorter than normal. Foreshortened muscles hurt. When stretched or gently worked out, the pain is apt to go away. Thus, the most important treatment for myofascial pain is exercise and stretching, including functional restoration if you are really hurting. Lack of sleep worsens myofascial pain, but so does excessive rest. You'll start to ache all over if you spend several days in bed.

Most people don't realize how important stress can be in causing and maintaining myofascial pain. Moreover, learning relaxation can dramatically reduce the pain you're in, regardless of the underlying cause. Blocked anger is also a major contributor.

Last updated Fri, Nov 25, 2005

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