Primary vs. Secondary Pain‍

If you’re one of the many people who’ve gone to see your primary care physician, orthopedist, or pain specialist who’s been told they don’t see an underlying injury or other tissue damage to explain your chronic pain, you are not alone. So many of us living with chronic pain have been told by medical professionals some version of “there’s nothing wrong with your body; it’s all in your head.”

Modern pain science has some critical insight to offer on the misguided and unkind “all in your head theory.” Research suggests that you may be experiencing primary pain rather than secondary pain.

What is Secondary Pain?

To understand the difference, let’s start with secondary pain. It’s the type of pain caused by injury, tissue damage, or disease that we’ve all traditionally thought of as simply “pain.” And tp be sure, that pain is very real. After all, if you sprain your ankle or live with osteoarthritis, there is damage to your joints, tendons, or muscles that can be found on an x-ray or other scan. There’s inflammation in that area that causes pain and can cause further degeneration or damage. There’s something for a doctor to point to and say, “That’s what is causing your pain.”

“Until really recently, this is how we thought of pain. That pain was something that happened because something was broken in your body, or was getting broken in your body, some kind of tissue damage or structural damage.”

Some examples of chronic secondary pain are:

• Cancer-related – from tumors, cancer that has spread beyond its original location, or even from treatments
• Headaches or orofacial pain – like the pain from a cavity or broken tooth, or TMJ
• Musculoskeletal – persistent inflammation due to an autoimmune disease, osteoarthritis, or multiple sclerosis
• Neuropathic – includes nerve damage in the spine (central) or in your limbs (peripheral), the effects of a stroke, and brain or spinal cord injury
• Postsurgical or post-traumatic – the painful sensations from spinal surgery, whiplash, or an amputation
• Visceral – recurring inflammation of internal organs, vessel constriction or another alteration of blood flow, or gallstones

Often, secondary pain isn’t the disease or malady itself but a symptom of it. Sometimes secondary pain lingers in our bodies long after the cause has been successfully treated: Residual pain long after surgery, nerve damage, or lingering lower back pain from an old injury that’s otherwise healed.

The traditional approach to treating chronic secondary pain is, recommending over-the-counter or prescription medications, a RICE (rest, ice, compression, and elevation) protocol when possible, physical or occupational therapy, and in some cases, manual therapies like massage and acupuncture. For the most part, these solutions provide at least temporary relief of secondary pain. But these treatments don’t always offer long-term relief for those of us for whom chronic pain is a daily struggle.

And what if none of these explanations apply to you?

What is Primary Pain?

First, we’ll say that this is very new science, and not many doctors are trained in correctly diagnosing and treating primary pain. The guidelines for this scientific breakthrough in chronic pain were only introduced in January of 2022. But chronic primary pain is, in fact, very common.

“Primary pain is pain that is driven by the pain signaling network and can exist even in the absence of tissue damage – causing changes in the brain’s pathways and very real pain.”

Primary chronic pain doesn’t have a structural issue or any damage that a doctor can point to as its source. Simply put, it’s pain that comes from misfired signals – triggers that are typically thought of as just emotions, like fear, anxiety, and depression.

Dr. Howard Schubiner, the “unlearn your pain” doctor, points to the examples of being embarrassed and the fear of public speaking to show how the brain’s misfiring often results in physical reactions and pain. Turning red in the face, sweating or feeling stomach cramps before having to stand up in front of a crowd. Sound familiar? We can all relate to these physical manifestations of the emotions of stress and fear. They’re the body’s way of trying to protect us from something it deems harmful (and public speaking can sure feel that way!).

A doctor can diagnose you with primary chronic pain in one of two ways: By ruling it in or by ruling out other issues. When your PCP has conducted clinical tests and sent you for imaging and can’t find any tissue damage or underlying structural cause for your pain, then they can rule out.

In order to rule in primary pain, physicians will look at the following:

• Pain that’s lasted at least 6 months
• If you’re feeling pain or discomfort in multiple areas at once
• Inconsistent levels of pain – really bad one day, not so bad the next – or pain that gets worse with stress
• A history of chronic pain, harmful childhood experiences, and/or treatments or surgeries that didn’t alleviate the pain
• History of treatments, injections, or surgeries that have failed to stop the pain 

What Does a Primary Pain Diagnosis Mean for Me?

It can actually be really good news to get a diagnosis of primary pain. No, really, there’s hope! 

“The primary pain diagnosis…the best diagnosis in the world to receive because it is really reversible, treatable, and means that your body's in great shape.”

Once you know that you’re dealing with primary pain, you can seek out integrative treatments to address the root causes of your pain. Give up your spot on the pain -> fear -> pain merry-go-round, and opt instead for talk and cognitive behavioral therapy, learning techniques to squash anxiety before it has a chance to cause more pain, and building new habits to improve your sleep, your mood, and–most importantly–your movement.

This is what the Lin program is all about. You’ll get a one-on-one consultation with a Lin medical provider to determine if your pain is primary or secondary. Once we’ve established that Lin is right for you, you’ll be given a pain recovery plan and assigned a private health coach who will help prioritize your steps and walk with you as your work on your plan. Your coach will help you integrate brain-first pain recovery techniques into your daily life, and stick with you every step of the way; help pick you up when you need it and celebrate your successes. The road out of chronic pain starts here.  

Let all of us at Lin just say it again: YOU ARE NOT ALONE.