– 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.


>The loneliness of the sufferer


Pain makes us feel small, vulnerable, defenseless.

Homo sapiens (ma non troppo) is raised under the caretaker’s protection, someone who is close to be requested when uncertainty projects anxiety, fear …

The caretaker detects and cares, thoughtfully, the creature’s complaints and calms the abandonment with actions.

If the caretaker fails, does not listen or look, even when caring thoughtfully, he or she can not avoid confessing his or her powerlessness, anguish at the failure as a caretaker. The sufferer comes down, sinks into the pit of despair, of helplessness, of abandonment. The suffering creature is certain of loneliness. The promised land of remedy and relief for everything doesn’t exist.

– We don’t know what’s happening. It’s a mystery. We’ve tried everything and I don’t know what else I can do.

– How can it be that, with all these advances…?

All the caretaker can do is shrug and show the harsh and stark expression of helplessness and detachment.

When the sufferer was still a child, the caretaker showed up with the painkiller and the glass of water, with the crushed aspirin in a teaspoon with some sugar. The scoop contained certainty of relief and so it was. The headache vanished with the simple logic of childhood.

– My head hurts …

– I’ll bring you the painkiller.

Over the years the children remained with their complaints, but each time the gesture of the caretaker was less confident and effective. The home reliever was no longer useful. First a doctor, then the specialist … until reaching the edge of the cliff.

The suffering (troppo) Homo sapiens (ma non troppo) remains the same creature, educated in the figure of the omnipresent, omniscient and omnipotent caretaker, but has lost the certainty or, even worse, has the certainty of fraud.

– It hurts so much… somebody help me!

Experts continue to increase the list of “Science’s” spectacular progress.

– We can take a picture (in color) of pain. We know where the brain creates it.

The sufferer gives an uncertain sigh of hope: “If you knew where the factory of pain is, you could drop some chemical bombs there and stop it…”

There are experts for everything. Those politically correct (as politicians) like anticipating results, but there are also those politically incorrect and scientifically honest that add their point of incorrection (political) embittering the sweetness of promises.

– Actually, the brain areas responsible for pain are also responsible for all relevant states, including the perception of social exclusion.

Brain facilities allegedly responsible for the pain, the so-called neuromatrix of pain, also show off their red color in the Functional Magnetic Resonance when something relevant happens or someone is very lonely.

– It hurts, something is going on in there, I feel helpless and misunderstood.

– You were right …. Look, this red area indicates that your brain is hypersensitive and that it activates the areas responsible for giving importance to things even if they’re not important, and making you feel lonely even when you’re accompanied. You have hyper relevance syndrome and social self-exclusion. It could be the serotonin, dopamine … or of course the genes …

– Is there any treatment for this?

– At the moment, we have no drugs that turn the brain into what we wish, but the only thing you can do is accept your situation. You must identify everything that your brain considers important and avoid it, without leaving aside your relationships with people, so you don’t feel that alone.

– You told me to get into a dark room and not talk to anyone…!

>Pain and necrosis


– My chest hurts …
– You’re having a heart attack.

The heart is a muscle that works tirelessly to give blood (chemical energy) to every cell of the organism. If it doesn’t get any blood (chemical energy) the heart muscle breaks down in a violent way. Necrosis happens. Neurons that keep an eye on necrosis detect their signals and send messages to the brain. The brain receives the necrotic message and, maybe, maybe not, it activates the chest pain program.

– You’re having a heart attack.
– But it doesn’t hurt.

There is no equivalence between pain and necrosis. There is pain without necrosis and necrosis without pain. No signs of necrosis are enough or necessary to initiate the perception of pain.

In physical threat conditions with a fight-fly defensive response, pain may be absent. When running away from a lion who wants to eat us we can be harmed by scratches without feeling (or at least suffering) any pain. Stress is analgesic. Exercise is analgesic.

It was thought that painless heart attacks occurred mostly in diabetic patients who had damaged vigilant neurons. When no necrosis was found, the brain was not aware of the incident and the alarm of pain would not turn on.

That is what was once thought and defended … until they found it was not true. One can have a heart attack, produce necrotic cellular signals, be collected by the corresponding vigilant neurons, those signals then be brought to the brain and, inexplicably, no alarms go off. Apparently nothing relevant happens in the chest …

– Can’t you give me something to make it hurt when I have a heart attack?
– We have drugs to take away the pain but not to create it.

If relievers exist, then there should be “agitators” too. In the end, everything is chemistry. The organism has relievers and agitators and uses them according to its evaluations to calm and agitate the individual.

– Necrosis? So what? Keep running. Endorphins. No pain.

– I know that there’s no necrosis but I’m afraid to move and mess it up… No endorphins. Cholecystokinin. Pain.

The brain has its reasons and applies them by removing or creating pain, by calming or agitating.

Homo sapiens (ma non troppo) tries to impose his or her own and offers all kinds of solutions.

– It hurts.
– Don’t worry. Here you go some sedatives.

– It still hurts.
– It can’t be. We gave you morphine. You will have to go to the Psychologist’s office.


– My chest hurts so badly. I’m dying…!
– Relax, we’ll take away the pain now.


– Give him some saline. This guy has nothing. He’s a hypochondriac.


– How are you feeling?
– It doesn’t hurt anymore. The calming effect worked.


– I already told you he had nothing. He can go home.

A placebo can remove the pain of a heart attack. The placebo does not work as a test that distinguishes necrotic pain from the “psychological” one. Any therapeutic action (real or apparent) can cause the brain to turn off the pain (neurons ON) and activate the analgesia (neurons OFF).

The executive brain (prefrontal) evaluates and decides. Turns on and off. Calms and agitates.

– Necrosis? Now we’ll think it over and then decide.

– I know that there is no necrosis… at the moment. But things can change. So I’ll activate some pain.

As said above: the brain has reasons unknown to the individual.

The individual has reasons that the brain often disregards.