– I think I understand. It makes sense. I think what you explained is true. But… what should I do?

A patient with migraine came to my office. Sitting next to me was a resident that was skeptical about the approach.

– How you doing?

– Okay. I haven’t had any more migraines. I don’t take meds. Sometimes I feel some pain but I control it.

– Explain to the doctor how you do it…

– I rationalize. I think quickly about what I’ve learned. I know that nothing is happening and I concentrate on what I’m doing.

We are instructed in the idea that something should necessarily be done to dissolve the pain. That something may be introducing a molecule with supposed powers to neutralize a supposed chemical responsible for pain: a needle, a herbal infusion, homeopathic products, meditation … Something added, aimed specifically at returning to normal.

In my office, I explain the basics of neurology of pain. Two objectives: dissolving errors and providing reliable knowledge. The perception of pain without justification has been activated. The brain has overestimated the probability of a destructive event. It’s not true that there is necessarily something wrong. The evaluative error is enough. False alarm. The apparent effectiveness of the reliever just indicates that the brain required the action of taking it and that this has dissolved the (wrong) assessment of threat. Nocebo to activate the alarm and placebo to deactivate it.

– Why does it hurt?

– Nocebo effect.

– How do I fight the nocebo?

– There are two ways: with placebo (doing something) or the conviction that nothing happens.

– I know that nothing is happening but even so… it hurts. At the end I have to take the painkiller. I need it.

Under experimental conditions we can get that when an inert cream is applied to the forearm before undergoing stimuli generators of pain (laser, heat …) the pain perception increases or decreases by changing one word of information:

– With the cream, you’ll feel less pain …

– With the cream, you’ll feel more pain …

It’s the same cream. A spoken word is a mechanical stimulus that generates a wave train that the ear captures … A change in the wave train is enough to increase or decrease pain. We can write information: moreless… In this case the word generates a subtly different light stimulus, sufficient to induce more or less of pain.

The pain therapies activate previously built expectations, by own experience, observing others’ experiences and instruction.

The observation of an analgesic action by placebo facilitates the placebo in our own flesh.

The duration of pain after the application of noxious stimuli varies if we trick the clock (one lap of the hands in 45 seconds.)

Knowing that a placebo was given doesn’t eliminate the analgesic action. The brain calls for action even knowing that such action doesn’t have anything relevant. Placebo. Deception.

The pedagogy of pain seeks to dissolve the false belief networks that feed the activation of false alarms. It seeks to dissolve the “nocebo-ness”, informative and cultural viruses. One of those viruses is the one that requires the therapeutic action, the cleansing ritual, the antidote to what (supposedly) makes it hurt.

The antidote for the nocebo is not placebo but the anti-nocebo, the anti-virus, not the virus of opposite sign.

– I understand, but I don’t know how to change my mindset…

– You’ll need to find out.

As Sol del Val said, everyone has their personal migraine and should explore it from the new interpretive frame provided by neurobiology.

Paradoxically, the patients with most migraines, most rebellious to treatment have a better response. They work in advance. They have tried all the therapies and are already disappointed. They need something new, different, contrary to what they so far have been provided.

Rationalization doesn’t have a good reputation. We forget the emotional part. There’s always someone …

An emotion is a state in which the organism assesses relevance, transcendence. Pain is the expression of the most powerful emotional state of the organism: the possibility of cell death, necrosis. Irrational fear is fought with rationality.

– I rationalize. I think about what I’ve learned. I continue with my homework.