Your Pain Has a Volume Knob, and It Can Be Turned Down
How much pain bothers you is weighed next door to the part of your brain that keeps you going.
In a video last month, I talked about a strip of brain that helps you push through things you would rather quit. I left something out: that same strip also helps decide how much your pain bothers you.
In clinic I ask my spine patients to rate their pain from zero to ten, and two people with the same number can be having very different weeks. That number hides two questions, and your brain answers them in separate places. One of the answers can be turned down.
Strength and bother come apart
For pain that nothing else can touch, neurosurgeons have sometimes made a small lesion in the front-middle part of the cingulate, the strip shown above. A 2024 review of the early reports says patients found the pain less bothersome.1
It is a rare last resort, used less in recent years, and never an option for readers. I have never performed one, since it belongs to another branch of neurosurgery.2
A 1997 experiment split the two without surgery. Under hypnosis, people were told the same painful test would bother them more or less, and only their bother ratings moved. On brain scans, the front of the cingulate followed the bother while the main sensory area held still.3
The neighbour, and the dial you can turn
Within that strip, the bother patch sits right beside circuitry for starting things and keeping at them. In a small study, patients who had the operation did worse on tests of starting actions on their own. In 2018, researchers pooling brain scans from many studies found pain and self-control in separate patches, like two circuits on the same street.5
You can also turn the bother dial down without an operation. In a large trial in long-term back pain, some adults took an eight-week course in mindfulness or in CBT, a structured talk therapy. Six months later, about 44% said their pain bothered them much less, against 27% on usual care.6
A second trial tested a newer talk-based treatment called pain reprocessing therapy. About two in three who had it ended up pain-free or nearly so. On scans, the front-middle cingulate, roughly where the old operation was aimed, reacted less to pain than it did in a placebo group.7
| Year | Study | Finding |
|---|---|---|
| 1997 | Rainville et al. Science | Hypnosis changed how unpleasant the same pain felt while its intensity held. Anterior cingulate activity changed; primary sensory cortex did not. |
| 1999 | Cohen et al. Neurology | 12 patients after cingulotomy for intractable pain. Lasting deficits at 12 months in intention and spontaneous action. |
| 2016 | Cherkin et al. JAMA | 342 adults with chronic low back pain. Clinically meaningful drop in bother at 26 weeks: 43.6% (mindfulness), 44.9% (CBT), 26.6% (usual care). |
| 2018 | Kragel et al. Nat Neurosci | 270 people, 18 scan studies. Pain mapped to the anterior midcingulate, cognitive control to parts of the dorsal midcingulate. |
| 2022 | Ashar et al. JAMA Psychiatry | 151 adults, mild to moderate back pain. Pain-free or nearly: 66% (reprocessing), 20% (placebo), 10% (usual care). On fMRI, less anterior midcingulate response than placebo. |
The surgical reports are observational and pain strength often fell too, as it did in the course trial, so the clean split comes from the hypnosis study. The reprocessing trial’s authors have financial ties to pain-therapy companies.
From one painful signal to the dial you can turn.
- A painful signal reaches two places The sensory cortex maps its strength, and the front of the cingulate weighs how unpleasant it is.5
- Hypnosis moves only one Only the cingulate followed a change in bother.3
- Surgery there eased the bother A rare, last-resort lesion left pain less bothersome.1
- The neighbour felt it too After the operation, patients did worse on tests of starting actions on their own.4
- Practice can turn the dial down If your pain has lasted months, ask your doctor about an eight-week course, added to your current care.6
Where this gets ahead of the evidence
“So my pain is all in my head.”
No
Strength and bother are two real parts of the same pain, and nothing in these studies says anyone imagined theirs.
“Hypnosis will switch my pain off.”
Lab only
That result came from a test pain in a lab, and it was never a treatment trial.3
“A course can replace my treatment.”
Never
A course goes alongside your current care, and your doctor stays in charge of it.6
“Pain reprocessing therapy cures back pain.”
Not shown
It did well in one trial in milder back pain and needs repeating. Across many trials, talk therapies ease long-term pain by a small amount.8
Next time someone asks how bad your pain is, you have two answers, and you can work on the bother. Two numbers, two neighbours, one strip of brain.
References
- Kollenburg L, et al. The cingulum: a central hotspot for the battle against chronic intractable pain? Brain Commun, 2024
- Sharim J, Pouratian N. Anterior Cingulotomy for the Treatment of Chronic Intractable Pain: A Systematic Review. Pain Physician, 2016
- Rainville P, et al. Pain affect encoded in human anterior cingulate but not somatosensory cortex. Science, 1997
- Cohen RA, et al. Impairments of attention after cingulotomy. Neurology, 1999
- Kragel PA, et al. Generalizable representations of pain, cognitive control, and negative emotion in medial frontal cortex. Nat Neurosci, 2018
- Cherkin DC, et al. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA, 2016
- Ashar YK, et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry, 2022
- Williams ACC, et al. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev, 2020
Figure. Cingulate gyrus, Gray’s Anatomy (1918), Henry Vandyke Carter, coloured by was_a_bee, public domain, via Wikimedia Commons.
