Skip to main content

Chronic Primary Pain Guidelines

Definitions​

  • Chronic Pain: pain longer than 3 months
  • Chronic Primary Pain: pain with no clear underlying cause, or pain (or its impact) which is out of proportion to observable injury or disease. There are several diagnoses under this heading (fibromyalgia, CRPS, chronic primary headache etc)
  • Chronic Secondary Pain: pain secondary to an underlying cause 1

Assessment​

  • Use clinical judgement to inform the search for an underlying cause
  • Explore the effect their chronic pain has on their life, and the lives of those around them
  • Consider investigating new symptoms during a flare-up

Education​

Discuss with the person with chronic pain and their family or carers (as appropriate):

  • the likelihood that symptoms will fluctuate over time and that they may have flare-ups
  • the possibility that a reason for the pain (or flare-up) may not be identified
  • the possibility that the pain may not improve or may get worse and may need ongoing management
  • there can be improvements in quality of life even if the pain remains unchanged

Managing Chronic Primary Pain​

Non Pharmacological

  • Supervised group exercise programme
  • Encourage physical activity
  • Offer acceptance and commitment therapy (ACT) or CBT
  • Acupuncture

Pharmacological

  • Antidepressant (amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline) - off label use
    • Used to improve quality of life, pain, and sleep in the absence of depression

Do Not Initiate​

  • Antiepileptics including gabapentinoids
  • Antipsychotics
  • Benzodiazepines
  • Trigger point injections
  • Ketamine
  • Topical local anaesthetic
  • NSAIDs
  • Opioids
  • Paracetamol

If the patient is already taking these:

  1. Explain the lack of evidence in chronic primary pain
  2. If the patient reports a benefit and few harms, agree a plan to continue safely
  3. If they report little benefit or significant harm, support in stopping the medication
    1. Consider trial of reduced dose

Do Not Offer​

  • Biofeedback
  • TENs
  • Ultrasound
  • interferential therapy

See Also​

NICE Guidelines: headaches, lower back pain, sciatica, rheumatoid arthritis, osteoarthritis, spondyloarthritis, endometriosis, neuropathic pain, and irritable bowel syndrome

  1. NICE Guidelines: headaches, lower back pain, sciatica, rheumatoid arthritis, osteoarthritis, spondyloarthritis, endometriosis, neuropathic pain, and irritable bowel syndrome↩