How to beat pain for good: the cutting-edge science, the expert medical views... and the surprising therapies that could work for you, revealed by top doctors

EXCLUSIVE How to beat pain for good: the cutting-edge science, the expert medical views...

and the surprising therapies that could work for you, revealed by top doctors By CHARLOTTE DOVEY Published: 01:28, 16 November 2024 | Updated: 01:35, 16 November 2024 e-mail View comments Everyone experiences pain from time to time – but while for most of us the discomfort of an injury, for instance, will pass as it heals, many people can endure months or even years of it – known as chronic pain. This can take a huge toll on their work, relationships and social lives. And the number of people affected is only likely to grow – we're living longer so are more likely to experience chronic diseases associated with pain.



Sometimes there may be no obvious physical cause. 'Whilst chronic pain [defined as lasting more than three months] can be as a result of medical conditions such as arthritis, cancer or diabetes , in many cases the cause is not obvious despite multiple investigations,' says Dr Alan Fayaz, a consultant in anaesthesia and pain medicine and chair of the Communications Committee at The British Pain Society. Another problem is that pain is subjective, which can make it hard to assess.

Understanding what drives chronic pain is clearly key to effective treatment and improving patients' quality of life. With chronic pain, in some cases the cause may have been treated but the pain continues or seems disproportionate Why it's still painful Pain is essential to our survival – an alarm telling us something is wrong. 'When you're injured, trauma causes inflammation which activates pain-sensing nerves that use chemical and electrical signals to send messages through the spine to the brain,' explains Dr Fayaz.

'The brain processes these and makes a decision on what to do. It might release endorphins, our natural painkillers, or tell your immune system to start healing the injury.' He adds: 'With acute pain, the pain makes sense: there's a reason for it.

' But with chronic pain, in some cases the cause may have been treated but the pain continues or seems disproportionate. 'This is known as 'wind-up' phenomenon – the body's warning system essentially becomes over sensitised,' adds Dr Mowafak Abdelghani, a consultant in pain medicine and anaesthesia at Manchester University Hospitals NHS Trust. It's like a fire alarm still ringing even after the fire has been put out.

In another group of people, there's no identifiable cause – here, chronic pain is thought to be due to faulty pain messages in the pathway in the spine being sent to the brain. 'This process also has links to the emotional centres of the brain,' says Dr Abdelghani. 'Studies have shown direct links between anxiety and stress, for instance, and a lower pain threshold.

And because pain itself makes you feel stressed, it can create a vicious cycle.' Dr Fayaz adds: 'Fortunately, we've made some very important advances in knowing how to support people in chronic pain; we no longer only focus on the biology, which medicines may address – we now also look at the social and psychological impact on an individual's life. 'It's a far more holistic approach which is helpful to a broader group of patients.

' So while doctors might not be able to 'cure' chronic pain, 'we're now much better placed to help people live better with it', he says. And here, in the latest of our essential guides on common ailments, we've joined forces with leading experts to bring you the most up-to-date advice on how to tackle chronic pain. Dr Alan Fayaz is a consultant in anaesthesia and pain medicine and chair of the Communications Committee at The British Pain Society When to seek urgent advice Chronic pain accompanied by certain symptoms need to be checked by your doctor.

Pain consultant Dr Alan Fayaz says these symptoms include: SUDDEN WEAKNESS IN THE LEGS: With back pain, numbness in the groin and/or loss of bladder or bowel control could be a sign of cauda equina syndrome. This is where nerve endings at the base of the spinal cord become compressed. Other symptoms include a prickling sensation in the backs of legs, bottom, hips and inner thighs.

It's a medical emergency – you should call 999 or visit A&E immediately. A CHANGE IN PAIN AFTER CANCER: 'Chronic pain is common after cancer treatment. If you experience any changes in the type of pain, or if it worsens, ensure your doctor knows about it.

PAIN THAT WAKES YOU UP: If you only experience pain when it wakes you up at night, it could mean the cause is structural – such as joint damage. Be sure to tell your doctor so that they can make further assessments. Do you have a low pain threshold? Why can some people hold a hot plate with ease, while others find it unbearable? Past experiences and emotions can play a part – particularly negative childhood exposure – increasing the sensitivity of the nervous and immune system.

As a result, a relatively trivial incident can trigger the memory and even amplify the perception of the original pain, explains pain specialist Dr Deepak Ravindran. People who are obese may have lower pain thresholds, partly because fat produces chemicals that trigger inflammation and pain. Women seem to feel pain more intensely, which may have an evolutionary drive: their immune and nervous systems are essentially 'wired' to be overprotective, translating to a low-pain threshold so they get out of harm's way quicker, to ensure survival, he adds.

But it's also more socially acceptable for women to talk about pain, so whether their tolerance is worse is still up for scientific debate, explains Dr Ravindran. Painkillers include anti-inflammatory drugs, paracetamol, NSAID gels, antidepressants, opioids and gabapentinoids From paracetamol to gels and antidepressants..

. which is the right painkiller for you? It can be hard to know what to choose – or, perhaps, to understand what you've been prescribed. Here experts explain the most common options.

Anti-inflammatory drugs NSAIDs (non-steroidal anti-inflammatory drugs) – such as aspirin, ibuprofen or prescription-only diclofenac and naproxen – block chemicals known as prostaglandins. These are produced by the body in response to trauma, causing swelling, pain and fever. PROS: 'NSAIDs are available over-the-counter, cheap, fairly fast-acting and ideal for acute pain,' says Mohammed Patel, a clinical pharmacist for Lancashire & South Cumbria NHS Foundation Trust.

'They can also be used for some chronic pain conditions such as arthritis.' CONS: Common side-effects include heartburn, stomach ulcers and gastrointestinal bleeding (NSAIDs block prostaglandins' protective mechanism, helping maintain the stomach lining). Not suitable for long-term use; can cause liver damage and raise your risk of stroke and heart attack.

BEST FOR: 'Acute injuries such as back pain; musculoskeletal injuries such as sprains, fever and short-term headaches,' says Dr Deepak Ravindran, a consultant pain specialist at the Central Reading Primary Care Network. Paracetamol Surprisingly, the mechanism behind paracetamol still isn't fully understood; one theory is that it works on inflammatory pathways. PROS: This is available over-the-counter, cheap and fairly fast-acting.

You can also take it with other pain relievers as it doesn't interact with many, plus it's generally well-tolerated without the side-effects of NSAIDs. CONS: May cause nausea and vomiting. BEST FOR: 'Acute pain such as minor aches, musculoskeletal injuries and headaches,' says pain consultant Dr Mowafak Abdelghani.

'It's also good for arthritic pain.' NSAID gels As with NSAID pills, the gels (e.g.

Fenbid ibuprofen gel or Voltarol diclofenac gel) block prostaglandins, which are produced in response to trauma or inflammation. The difference is the gels are absorbed through the skin and reduce inflammation locally. PROS: Gels tend to be fairly cheap and can be used as required.

They also have a lower risk of side-effects than oral NSAIDs. CONS: Not available on NHS prescription and can be costly if used regularly: sticky on skin. BEST FOR: Localised swelling of joints, muscle aches and arthritis, according to pain medicine specialist Dr Alan Fayaz.

Antidepressants Tricyclics (e.g. amitriptyline and nortriptyline) and serotonin and norepinephrine reuptake inhibitors (SNRIs) such as duloxetine and venlafaxine – all prescription only – increase levels of chemical messengers such as serotonin and noradrenaline in the brain and nervous system which effectively calm down pain signals.

PROS: 'Especially good for nerve pain, and if that pain keeps you awake, as they have a sedative effect,' says Laura Wilson, director of the Royal Pharmaceutical Society in Scotland. CONS: Side-effects include drowsiness, constipation, blurry vision and confusion, plus weight gain and sexual dysfunction if used long-term. 'And they can take several weeks to take effect,' says pharmacist Mohammed Patel.

BEST FOR: 'Migraine, some types of chronic pain and nerve pain, particularly diabetic neuropathy [diabetes-related] and sciatica,' says pain medicine specialist Dr Alan Fayaz. Opioids Some weaker opioids, such as codeine and dihydro-codeine are available over the counter (brands include Solpadeine Max and Migraleve); stronger formulations such as morphine, oxycodone and fentanyl are prescription-only. Opioids bind to receptors in the brain and nervous system, blocking pain signals.

PROS: Over-the-counter opioids are effective for acute pain; stronger opioids work well for cancer-related or post-surgical pain. CONS: Side-effects can include constipation, nausea and vomiting as the drugs slow the muscles in the gut. Opioids can also cause memory and concentration problems because, as well as numbing pain, they essentially 'numb' the brain, says Dr Abdelghani.

They can also cause medication-overuse headaches. There are well-known risks of addiction and withdrawal effects. For non-cancerous chronic pain, the risks often outweigh the potential benefits, according to the National Institute for Health and Care Excellence.

BEST FOR: 'Cancer pain, end of life/palliative care, acute pain and post-surgical pain,' says Dr Ravindran. 'Short-term use (for one to two weeks) of weak opioids sometimes helps with headaches.' Gabapentinoids These potent drugs were developed to treat epilepsy and depression, but they are used in low doses for nerve-related pain – acting on a receptor on the nerves that send pain signals to the brain, or calming down nerve activity in the brain.

They are available only on prescription. P ROS: Drugs such as gabapentin and pregabalin, can be effective for neuropathic (nerve) pain, and 'may also help with the additional symptoms associated with pain such as poor sleep and anxiety', says Dr Ravindran. 'This is because they mimic the brain chemical GABA, which causes feelings of relaxation.

' CONS: They don't work for some, can also cause dependence and lead to weight gain and 'brain-fog'. BEST FOR: 'When other anti-nerve medication has been unsuccessful, these drugs can help with neuropathic pain such as sciatica,' says Dr Ravindran. Throbbing pain on one side of the head that's worse when you move, sometimes with nausea or light sensitivity, might be a migraine If you struggle with chronic headaches.

.. Here, experts help identify what could be causing your headache – and the latest treatments for it.

Throbbing pain on one side of the head that's worse when you move. Sometimes with nausea or light sensitivity. MIGHT BE: Migraine.

Migraines are thought to be due to abnormal activity in the brain, which then affects the nerves that send pain signals. In women, they can be related to hormones: 'There is a natural drop in oestrogen just before a period, and it's this sudden imbalance that's the link to what's known as a menstrual migraine,' says Dr Lisa Rodolico, a GP and headache specialist at the National Migraine Centre charity in London. They're stronger and last longer, starting two days before and lasting three days of the period.

TREATMENT: 'Most over-the-counter medication is unlikely to be strong enough for migraines,' says Dr Anna Andreou, a senior researcher at the Headache Research Laboratory at King's College London. More potent drugs called triptans, like sumatriptan (available over the counter; others such as frovatriptan are prescription-only) can help prevent them. DID YOU KNOW? Redheads are more sensitive to pain and may need more dental anaesthetic, reported the American Dental Association in 2019 – possibly because the red hair gene is involved in pain receptors in the brain.

Advertisement As pain consultant Dr Mowafak Abdelghani explains: 'During migraines, blood vessels can widen. Triptans bind to the receptors in the brain that control vessels which narrows them. They also help calm pain signals.

' Nasal or oral triptan sprays are helpful if migraines cause nausea or vomiting. There are other options, says Dr Andreou. 'A newer theory is that a protein called CGRP may relay pain signals around the brain and cause inflammation, making the pain worse.

Prescription-only drugs, like monoclonal antibodies can help target this protein.' Even newer are gepants, drugs that bind to the CGRP receptor, blocking its effect. Botox can be effective – freezing nerves and stopping pain messages.

While hormone treatments, such as the Pill, may help menstrual migraine. Dull pain that often wakes you up; often every day. MIGHT BE: A medication over-use headache.

Over-using headache pills can lead to withdrawal symptoms as they wear off, causing another headache and a vicious cycle. 'Overuse is taking painkillers two or three times a week for at least three months,' says Dr Rodolico. 'Most headache medicines have the potential to cause this – codeine is the worst offender.

' TREATMENT: While some people can just stop immediately, others need to reduce their dose over time. Seek your doctor's advice. Agonising pain on one side, often around the eye, that can occur in cycles.

Perhaps accompanied by sweaty face, red eyes and a blocked or runny nose. MIGHT BE: Cluster headache. This is thought to be linked to the hypothalamus, the part of the brain that runs the body clock, says Dr Andreou.

This may explain why attacks can occur at the same time each day, usually an hour or two after bedtime. They affect around 66,000 Britons, more often men and smokers, though it's not clear why. A common trigger is alcohol.

TREATMENT: An injection of sumatriptan can help within 15 minutes, as can pure oxygen (having a dampening effect on nerves that send pain signals). Oxygen canisters, delivered at home, are available on the NHS. Throbbing pain, often at the back of the head, when you stand (easing when lying).

It gets worse during the day; may be accompanied by nausea and stiff neck. MIGHT BE: Postural headache. Our heart rate and blood pressure are regulated automatically, to keep the blood flowing, whatever our position.

With postural orthostatic tachycardia syndrome (POTS), this goes awry, and standing up can reduce blood flow to the brain. 'POTS can be triggered by a number of things but bacteria or viruses, including coronavirus, seem to set it off most often,' says Dr Rodolico. It's diagnosed with a tilt table test: you're strapped to a table that's tilted up to a 70-degree angle as your heart rate and blood pressure are monitored.

TREATMENT: Wearing compression stockings can help. Drug treatments include beta blockers (e.g.

midodrine) which constrict blood vessels to raise pressure. Acupuncture can help your body to release natural painkillers, says pain specialist Dr Deepak Ravindran Alternative therapies that really do work Research shows that using a combination of alternative therapies and conventional medication can result in a greater reduction in pain. 'But it is important to ensure that the cause of your pain has been investigated first,' says Edzard Ernst, an emeritus professor of complementary medicine at Exeter University.

ACUPUNCTURE: 'Studies show that it can help your body to release natural painkillers,' says pain specialist Dr Deepak Ravindran. A 2016 Cochrane review suggested that it can be as effective for migraine as commonly prescribed drugs. Another study review found it can be better than usual care for chronic lower back pain.

It can help pain where there's no clear cause or when the pain is out of proportion to any observable injury or disease, says the National Institute for Care Excellence (NICE). This includes fibromyalgia, chronic muscle and joint pain and cancer-related pain, It's available in some GP and NHS pain clinics, and privately: for qualified acupuncturists visit: medical-acupuncture.co.

uk MASSAGE: 'The therapeutic benefits of touch in a safe and relaxing environment can enhance activity in the vagus nerve [the body's main nerve] which helps to reduce levels of cortisol, a stress hormone associated with pain,' says Dr Ravindran. This can relax muscles, reduce spasms and regulate breathing, which also helps reduce pain. CHIROPRACTIC TREATMENT: Chiropractors focus on the function of the spine and pelvis, using manipulation.

A 2019 review found that spinal manipulative therapy (SMT) was as effective for chronic lower back pain as exercise and NSAID drugs (see above). But if you have enhanced sensitivity to pain, SMT can 'amplify pain messages, making it worse', says Dr Ravindran. Ask your GP about having treatment on the NHS – or go to gcc-uk.

org , to find a private practitioner. SUPPLEMENTS: These can play an important role in chronic pain. However, some can interact with medication, so check with your doctor first.

For migraine, studies show riboflavin (vitamin B2) may help. NICE guidelines suggest 400mg per day. Riboflavin has antioxidant properties, thought to combat inflammation associated with migraine.

For arthritis or chronic lower back pain, Devil's claw – a plant native to Southern Africa – has been shown to be as effective as some medicines. It's thought to have anti-inflammatory effects. Rest? No, it's good to get moving 'Many years ago, the suggestion of exercise for chronic pain was laughed at,' says pain medicine consultant Dr Mowafak Abdelghani.

'But our knowledge of the mechanism behind chronic pain has changed. Whilst medication can help some, for many it doesn't. He says: 'We've learned that emotions, worries about money, isolation and family issues, all can have an effect on brain chemistry and increase the severity of pain you feel.

That's why painkillers can, for some, have little to no effect. This is where exercise comes in.' Jackie Walumbe, a physiotherapist at University College London Hospitals, adds: 'We're not necessarily talking about running or going to the gym.

In some cases, it's simple exercises that, over time, can change someone's mindset, so they move without fear. 'This could mean being able to get dressed or drive the car for ten minutes. It could mean standing up and cooking a meal.

' Research consistently confirms its benefits. A study in the British Journal of General Practice found that when patients with chronic pain and varying degrees of mobility were put on a ten-week exercise programme, it reduced their pain and improved their ability to go about daily activities. 'There are increasing numbers of GPs and community programmes that can put those with chronic pain in contact with medical professionals who can help them manage pain better and start living their lives again,' says Jackie Walumbe.

Ask about going to a pain clinic Feeling you've tried everything and nothing has worked, can, in itself, add to people's stress and pain. But there's a lot that can be done. Your GP can refer you to a pain clinic, specialist centres where doctors (usually anaesthetists who've had specialist training in pain medicine), specialist nurses, physiotherapists, psychologists and occupational therapists treat you 'holistically'.

Dr Alan Fayaz, a pain medicine specialist, says: 'This means that while they can still prescribe the latest drugs or give pain-relieving injections, they also take time to understand the mental and social impact of your pain.' One option is group pain management programmes – with exercise and teaching techniques such as mindfulness. 'Often these programmes are carried out with others in the same situation,' says physiotherapist Jackie Walumbe.

'The waiting time can be six weeks to two years, but some charities – for instance, Pain Concern, Action on Pain and Versus Arthritis – run self-help groups where you can meet others with long-term pain.' SPINAL CORD STIMULATORS: Another option, for patients with severe pain, where nothing has helped, is a spinal nerve modulator, says rheumatologist Professor David Walsh. 'This is sometimes used for spinal cord injuries and diabetic neuropathy [nerve damage caused by diabetes].

' Electrodes are placed between the spinal cord and the vertebrae; these are attached to a device implanted near the buttocks or abdomen. The patient can use a remote control to send electrical impulses that block pain signals to the brain. This option is only available in specialist centres; it costs around £35,000 privately.

JOINT REPLACEMENT: Replacing a worn-out joint with a new one can reduce chronic pain but it does make a difference which joints are being replaced. Hip replacements are most successful due to the biomechanics; a hip is a simple ball-and-socket joint whereas a knee is a hinge and more complex. Shoulders are complex, too.

Victoria Abbott-Fleming, 45, developed phantom pain syndrome after having both her legs amputated How mirrors can solve mystery of phantom pain The pain Victoria Abbott-Fleming feels every day in her legs is excruciating. One minute it's like they've been dipped in acid, the next as if they're being stabbed with ice-picks. This kind of pain would be awful for anyone, but for Victoria, 45, this is compounded by the fact her legs were amputated years ago.

It's something that affects nearly everyone who's undergone an amputation, including the thousands every year in the UK who have the surgery as result of diabetes complications. Victoria, who is married to Michael, 58, and lives in Derbyshire, was a young lawyer with everything to look forward to when, aged 23, she fell down some steps at work. Initially the fall caused just a minor cut and some bruising on her right shin, which swelled up.

But the swelling got worse – 'the shin was just so sensitive, even getting dressed was agony. I couldn't go back to work. 'As the months progressed, I had to use a wheelchair.

' Over seven months, Victoria saw 39 different specialists, including pain consultants and neurologists, before being diagnosed with complex regional pain syndrome (CRPS), a condition that affects around 16,000 Britons. It's thought to be caused by the body reacting abnormally to an injury. As Victoria's leg became more swollen, the skin started to split, leading to an ulcer that wouldn't heal.

'It was constantly weeping and the smell was just awful.' Over the next two years, she was in and out of hospital with infections until, in 2006, with no skin on her leg from the knee to the toes, she needed amputation of her right leg below the knee. She and Michael married three months before the operation – and Victoria hoped that the surgery would mark the beginning of a new chapter.

But a few months later, half asleep in bed, she felt a 'twinge – in the leg I no longer had'. Over time, this developed into pain 'that got worse and worse'. It was, she says, 'so cruel because it was just like CRPS except in the parts of the body I didn't have'.

Read More Our essential guide to beating back pain: What's causing your aches She'd developed phantom pain syndrome (which also affected her other leg following the second amputation in 2014). 'Phantom sensations occur in almost everyone who has an amputation,' says pain specialist Dr Deepak Ravindran. Up to 6,000 limb amputations are carried out in the UK every year, often as a complication of diabetes – phantom pain tends to occur within the first six months after the operation.

'Whilst you may have lost a limb, the brain's 'map' of the body is still intact,' explains Dr Ravindran. 'That area still has a neural circuit in the brain which continues to fire out messages that there's a problem in the leg even though there isn't.' This leads to sensations of pain, itching, tremors, burning or pinching, in the missing limb.

These symptoms can range from mild to severe and last for seconds, days or even years. Pain medication can help but is not always effective. Other treatments aim to block rogue pain signals sent by the brain, such as spinal cord stimulation (via an implant placed in the spine surgically) and transcutaneous electrical nerve stimulation (TENS machines).

Some patients are offered mirror therapy which involves doing exercises beside a mirror which covers the affected limb. Seeing the reflection of the unaffected limb working normally tricks the brain into thinking the amputated limb is still there, says Dr Ravindran. This reassures the brain all is well, calming the 'hyper-alert neurocircuits', so it won't send out false pain signals.

The sooner this therapy is used the better – after a year or two it can be hard to reprogramme the brain: success is also individual, says Dr Ravindran. One 2019 study found that mirror therapy reduced pain by 40 per cent in 89 per cent of amputees. Unfortunately for Victoria, who has founded the CRPS charity Burning Nights, it didn't work.

After nearly 20 years of pain, she relies on her pain 'toolkit', which includes distraction therapy – ensuring her mind is busy – as well as pacing her activities and chores (doing half the washing, for instance). 'It's taken a long time to get to this point' says Victoria, 'but I'm now able to manage my pain and, in many ways, live well. I feel lucky despite the many setbacks.

' For more details of the charity, see burningnightscrps.org Gadgets that can help ease the agony There are lots of devices that promise to help with chronic pain. Here Sammy Margo, a physiotherapist in London, suggests products that may be worth trying.

Weighted blanket Oodie, £47.50, theoodie.co.

uk FOR: All-over pain, such as fibromyalgia. In 2022, researchers at the University of California, found that people with chronic pain who spent a week sleeping with a heavy (15lb) blanket experienced a greater reduction in pain compared with a light (5lb) blanket. 'This is likely due to the calming effects of the deeper pressure,' says Sammy Margo.

Memory foam pillow Ortorex, £24.99, ortorex.uk FOR: Neck pain.

'Good supporting pillows are essential for neck pain,' says Sammy Margo. Memory foam helps align the spine. The Ortorex memory foam pillow helps align the spine, which is essential for neck pain TENS machine Myoovi, £69.

99, myoovi.co.uk FOR: Period pain, endometriosis.

TENS (transcutaneous electrical nerve stimulation) technology can stop pain signals reaching the brain. 'Studies show TENS is effective in reducing chronic pain – though not period pain [as this product is marketed for] in particular,' says Sammy Margo. Cold gel relief cap Gelpacks, £24.

99, gelpacks.co.uk FOR: Migraine.

The cold of an ice cap 'reduces blood flow to reduce inflammation and migraine pain – the numbing sensation of the cold can also help', says Sammy Margo. A study in 2006 found 25 minutes of wearing one reduced migraine pain. Researchers said that for some cold therapy alone could be effective for migraine attacks.

Joint relief massager Inzys, £79.99, inzys.com FOR: Back pain.

This vibrates to ease tightness or pain and improve circulation. A 2023 study found that vibration therapy increased mobility in patients with chronic lower back pain. 'I advise patients to use this for two minutes a day.

It's also good for pain in the hamstring, calf and mid-thigh,' says Sammy Margo. Ice cream headaches and heart attacks We've all eaten ice cream and felt brain freeze, extreme pain in the forehead; this is an example of referred pain, says pain consultant Dr Mowafak Abdelghani. 'It means the effects – here, extreme cold at the back of your throat – are felt somewhere different.

' It occurs because every part of the body is connected by a network of nerves that carry pain messages to the brain. As a result, the brain sometimes has trouble distinguishing the source, for instance, if the pain comes from an area that it isn't used to experiencing pain. A common example is sudden shoulder pain where the cause is actually the gallbladder.

Or upper-back pain could point to pancreatitis, an inflamed pancreas. 'It can be difficult to tell whether the pain is referred or not, but if you suddenly develop pain somewhere without any obvious reason, it could be that,' says Dr Abdelghani. But arm pain along with breathing difficulties, dizziness or chest pain can be a sign of a heart attack and need urgent medical treatment, he warns.

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