Is chronic pain in the brain?

You've had back or neck pain for a long time. The scans look reasonable, but the pain is still there. Maybe someone has told you that it's 'all in your head'. That feels unjust. Yet there is something true in that statement - but not in the way it often comes across.

Chronic pain is literally in the brain. Not as imagination, but as a biological process that has changed your nervous system. In this article we explain how that works, why back and neck pain so often become chronic - and what that means for how you can deal with it.

What is pain, really?

Pain is a protective mechanism of your body. It's not a passive feeling that happens to you - it's an active alarm that your brain sends when it estimates that there is danger. You hit your finger with a hammer: the brain receives a signal, assesses it as threatening and sends a pain signal back. You pull your hand away. Mission accomplished.

Pain is therefore not a direct measure of damage. It's a measure of how dangerous your brain estimates a situation to be.² That distinction is small but crucial, and it explains why chronic pain is so different from acute pain.

What is the difference between acute and chronic pain?

With acute pain - a sprained ankle, a strained muscle after heavy lifting - there is a clear cause. Your body sends an alarm signal, you protect the area, the tissue heals, the pain disappears. The system does exactly what it should do.

With chronic pain - complaints that persist longer than three months³ - the connection with the original damage has faded or disappeared. The tissue damage has often long since healed, but the pain remains. Sometimes it even gets worse. The alarm keeps going off, even when there's no fire anymore.

This is precisely why the treatment of chronic pain is fundamentally different from that of acute pain. You can't turn off the alarm by 'repairing' the damage - you have to address the alarm system itself.

Why does the pain persist? Central sensitization explained

When pain persists for a long time, your nervous system changes. The nerve pathways that transmit pain signals become sharpened: they conduct faster, respond to weaker stimuli and send stronger signals to the brain. This is called central sensitization.¹

Your brain plays an active role in this. It doesn't just process pain signals - it amplifies them, colors them with previous experiences, and links them to emotions, expectations and memories.¹ Stress, lack of sleep, anxiety and worry make the system even more sensitive.² You no longer need to receive a serious stimulus to feel severe pain.

This explains phenomena that many people with chronic pain recognize:

• Pain that gets worse after a bad night, even if you haven't done anything different

• Pain that increases under stress, even without physical exertion

• Pain that fluctuates without clear cause

• Pain that is more severe than you would expect based on a scan

Important: this doesn't mean that the pain is 'all in your head' or imagined. The pain is completely real - it's your nervous system responding the way it has learned to respond.¹ But that system is changeable, and that is hopeful.

Why do back and neck pain so often become chronic?

Not every pain becomes chronic. Why does back and neck pain so often do? Part of the answer lies in how we deal with these complaints - often from understandable, but unintentionally unhelpful patterns.

People with back or neck pain start avoiding movements that seem to trigger pain. They turn their head carefully, stop lifting, sit differently. In the short term this is logical - but in the long term the pain system learns that those movements are dangerous, even when they aren't.² In addition, your load capacity decreases, which lowers the pain threshold even further.

On top of that, the back and neck are central to almost everything you do: sleeping, working, driving, social contact. As a result, the complaints are constantly present in your awareness. This keeps the pain system active and alert - exactly the breeding ground for central sensitization.¹

→ Want to read more about how to balance load and load capacity? Read the article on load and load capacity in chronic pain.

What does this mean for treatment?

If chronic pain is an oversensitive alarm system, then there is little point in continuing to search for a physical cause that can be fixed. Treatment focuses on the system itself: calming the nervous system, building movement confidence and learning to deal with pain signals that are no longer reliable.³

What helps:

• Pain education: understanding how pain works makes it less frightening - and that reduces the sensitivity of the system²

• Gradual movement: showing your nervous system that movement is safe, even when it initially feels uncomfortable

• Psychological support: recognizing and addressing thoughts that amplify pain, for example through ACT (Acceptance and Commitment Therapy)

• Addressing amplifying factors: sleep, stress and tension directly influence how sensitive your pain system is¹

The goal is not to become pain-free. The goal is for pain to limit you less - so that you can do what matters to you again, even if pain signals are still there.

Is RealHealth something for you?

RealHealth is an intensive pain management program from Sint Maartenskliniek, specially developed for people with persistent back or neck pain who, despite various treatments, remain limited in their daily lives.

The program is based on exactly the insight that is central to this article: chronic pain requires a different approach than acute pain. Not repairing, but learning to understand and use the pain system differently - so that you can function again, even if pain is still present.

Scientific research shows that participants still benefit from what they have learned years after the program.

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