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Chronic Pain: In Depth

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What’s the Bottom Line?

How much do we know about the effectiveness of complementary health approaches for chronic pain?

What do we know about the safety of complementary health approaches for chronic pain?

  • Although the psychological and/or physical approaches (e.g., acupuncture, meditation, yoga, massage) studied for chronic pain have good safety records, that doesn’t mean that they’re risk-free for everyone. Your health and special circumstances (such as pregnancy) may affect the safety of these approaches. If you’re considering nutritional approaches such as dietary supplements, remember that natural doesn’t always mean safe and that some dietary supplements may have side effects or interact with medications.

What Is Chronic Pain and Why Is It Important?

Chronic pain is pain that lasts more than several months (variously defined as 3 to 6 months, but longer than “normal healing”). It’s a very common problem. Results from the 2012 National Health Interview Survey show that:

  • About 25.3 million U.S. adults (11.2 percent) had pain every day for the previous 3 months.
  • Nearly 40 million adults (17.6 percent) had severe pain.
  • Individuals with severe pain had worse health, used more health care, and had more disability than those with less severe pain.
More Information

Chronic pain becomes more common as people grow older, at least in part because health problems that can cause pain, such as osteoarthritis, become more common with advancing age. Military veterans are another group at increased risk for chronic pain; U.S. national survey data show that both pain in general and severe pain are more common among veterans than nonveterans.

Not all people with chronic pain have a health problem diagnosed by a health care provider, but among those who do, the most frequent conditions by far are low-back pain or osteoarthritis, according to a national survey. Other common diagnoses include rheumatoid arthritis, migraine, carpal tunnel syndrome, and fibromyalgia. The annual economic cost of chronic pain in the United States, including both treatment and lost productivity, has been estimated at up to $635 billion.

Chronic pain may result from an underlying disease or health condition, an injury, medical treatment (such as surgery), inflammation, or a problem in the nervous system (in which case it is called “neuropathic pain”); or the cause may be unknown. Pain can affect quality of life and productivity, and it may be accompanied by difficulty in moving around, disturbed sleep, anxiety, depression, and other problems.1

For more information about chronic pain, visit the National Institute of Neurological Disorders and Stroke.

What the Science Says About Complementary Health Approaches for Chronic Pain

The scientific evidence suggests that some complementary health approaches may help people manage chronic pain.

A comprehensive description of scientific research on all the complementary approaches that have been studied for chronic pain is beyond the scope of this fact sheet. This section highlights the research status of some approaches used for common kinds of pain.

Chronic pain in general

Some recent research has looked at the effects of complementary approaches on chronic pain in general rather than on specific painful conditions.

  • A 2017 review looked at complementary approaches with the opioid crisis in mind, to see which ones might be helpful for relieving chronic pain and reducing the need for opioid therapy to manage pain. There was evidence that acupuncture, yoga, relaxation techniques, tai chi, massage, and osteopathic or spinal manipulation may have some benefit for chronic pain, but only for acupuncture was there evidence that the technique could reduce a patient’s need for opioids.
  • Research shows that hypnosis is moderately effective in managing chronic pain, when compared to usual medical care. However, the effectiveness of hypnosis can vary from one person to another.
  • A 2017 review of studies of mindfulness meditation for chronic pain showed that it is associated with a small improvement in pain symptoms.
  • Studies have shown that music can reduce self-reported pain and depression symptoms in people with chronic pain.

Low-back pain

  • A 2017 evaluation of the research on acupuncture found evidence that it has a small beneficial effect on acute low-back pain and a moderate beneficial effect on chronic low-back pain. Based on this evaluation, a 2017 clinical practice guideline (guidance for health care providers) from the American College of Physicians (ACP) included acupuncture among the nondrug treatment options for management of both acute and chronic low-back pain.
  • Massage therapy might provide short-term relief from low-back pain, but the evidence is not of high quality. Massage has not been shown to have long-term benefits for low-back pain. The 2017 ACP guideline included massage therapy as an option for acute but not chronic low-back pain.
  • A 2017 research review concluded that mindfulness-based stress reduction is associated with improvements in pain intensity and physical functioning in low-back pain, compared to usual care, but the effect may be small and short term. The 2017 ACP guideline included mindfulness-based stress reduction as an option for chronic but not acute low-back pain.
  • There is some evidence that progressive relaxation may help relieve low-back pain, but studies on this topic have been small and not of the highest quality. The 2017 ACP guideline included progressive relaxation as an option for chronic but not acute low-back pain.
  • Spinal manipulation appears to be as effective as other therapies commonly used for chronic low-back pain, such as physical therapy, exercise, and standard medical care. The 2017 ACP guideline included spinal manipulation as an option for both acute and chronic low-back pain.
  • A 2018 evaluation of the research on yoga for low-back pain by the Agency for Healthcare Research and Quality (AHRQ) found that it improved pain and function in both the short term (1 to 6 months) and intermediate term (6 to 12 months). The effects of yoga were similar to those of exercise. The 2017 ACP guideline included yoga as an option for chronic but not acute low-back pain.
  • A 2016 evaluation of the research on herbal products for low-back pain found evidence that cayenne, administered topically (applied to the skin) can reduce pain. Two other herbal products used topically, comfrey and lavender essential oil, and two herbs used orally, white willow bark and devil’s claw, may also be helpful, but the evidence for these herbs is not as strong as that for cayenne.
  • Studies of prolotherapy (a treatment involving repeated injections of irritant solutions) for low-back pain have had inconsistent results.
  • For more information, see the National Center for Complementary and Integrative Health (NCCIH) webpage on low-back pain.

Osteoarthritis

  • There’s evidence that acupuncture has short-term benefits in relieving knee pain caused by osteoarthritis. Acupuncture hasn’t been shown to be helpful for osteoarthritis of the hip.
  • A small amount of research suggests that massage may help reduce osteoarthritis symptoms.
  • A 2017 review of the evidence by the AHRQ concluded that tai chi has short-term (up to 12 weeks) and medium-term (12 to 26 weeks) benefits on pain for people with knee osteoarthritis. There hasn’t been enough research to show whether it’s helpful for longer periods of time. Qigong may have similar benefits, but little research has been done on it.
  • Little research has been done on yoga for osteoarthritis; there’s only weak evidence of a possible benefit.
  • The 2017 AHRQ report concluded that one type of electromagnetic therapy, called pulsed electromagnetic field therapy, may have a short-term beneficial effect on knee osteoarthritis pain, but the strength of the evidence for an effect was low.
  • The 2017 AHRQ report evaluated whole-body vibration (an approach in which a person does exercises on a vibrating platform) for knee osteoarthritis and found that its effects on pain were inconsistent.
  • Studies of glucosamine, chondroitin, and S-adenosyl-L-methionine (SAMe) for knee osteoarthritis pain have had conflicting results.
  • There isn’t enough research on dimethyl sulfoxide (DMSO) or methylsulfonylmethane (MSM) for osteoarthritis pain to allow conclusions to be reached.
  • For more information, see the NCCIH fact sheet on osteoarthritis.

Rheumatoid arthritis

  • The amount of research on psychological and/or physical approaches for rheumatoid arthritis pain is too small for conclusions to be reached about their effectiveness.
  • Dietary supplements containing omega-3 fatty acids, gamma-linolenic acid (GLA), or the herb thunder god vine may help relieve rheumatoid arthritis symptoms.
  • For more information, see the NCCIH fact sheet on rheumatoid arthritis.

Headache

  • There’s moderate-quality evidence that acupuncture may reduce the frequency of migraines and moderate-to-low quality evidence that it may reduce the frequency of tension headaches.
  • Because not much research has been done or because research results are inconsistent, it’s uncertain whether biofeedback, massage, relaxation techniques, spinal manipulation, tai chi, and yoga are helpful for headaches.
  • Butterbur appears to help reduce the frequency of migraines in adults and children. In 2012, the American Academy of Neurology recommended its use for preventing migraines. However, the Academy stopped recommending it in 2015 because of serious concerns about possible liver toxicity. 
  • For more information, see the NCCIH fact sheet on headaches.

Neck pain

  • Acupuncture hasn’t been studied as extensively for neck pain as for some other pain conditions. However, the studies that have been done suggest that acupuncture is helpful for neck pain, although its effect may not persist for long.
  • Massage therapy may provide short-term relief from neck pain, especially if massage sessions are relatively lengthy and frequent, but it doesn’t appear to be more effective than other therapies.
  • Spinal manipulation may be helpful for short-term relief of neck pain, but the evidence favoring it is not of high quality.

Fibromyalgia

  • It’s uncertain whether acupuncture is helpful for fibromyalgia pain.
  • Although some studies of tai chi, yoga, mindfulness, and biofeedback for fibromyalgia symptoms have had promising results, the evidence is too limited to allow definite conclusions to be reached about whether these approaches are helpful.
  • There is insufficient evidence that any nutritional approaches such as dietary supplements can relieve fibromyalgia pain, with the possible exception of vitamin D supplements, which may reduce pain in people with fibromyalgia who have low vitamin D levels.
  • Studies of homeopathy have not demonstrated that it is beneficial for fibromyalgia.
  • For more information, see the NCCIH fact sheet on fibromyalgia.

Irritable bowel syndrome

  • Hypnotherapy may be helpful for irritable bowel syndrome, but the quality of the evidence is not high.
  • Probiotics may be helpful for irritable bowel syndrome, but it’s still uncertain which types of probiotics are most likely to be effective and which symptoms they may relieve.
  • The small amount of research on peppermint oil suggests that at least some formulations might be helpful for irritable bowel symptoms.
  • Studies of acupuncture for irritable bowel syndrome have not found actual acupuncture to be more helpful than simulated acupuncture.
  • For more information, see the NCCIH fact sheet on irritable bowel syndrome.

Other types of pain

  • Various complementary approaches have been studied for other types of chronic pain, such as nerve pain, chronic pelvic pain, pain associated with endometriosis, carpal tunnel syndrome, pain associated with gout, and cancer pain. There’s promising evidence that some complementary approaches may be helpful for some of these types of pain, but the evidence is insufficient to clearly establish their effectiveness.

Other Complementary Approaches

  • There’s some evidence that cannabis (marijuana)-based medicines (i.e., cannabinoids) may be helpful for chronic nerve (neuropathic) pain and perhaps other types of chronic pain, but it’s unclear whether the potential benefits are greater than the potential harms. Further research is needed that meets U.S. Food and Drug Administration (FDA) requirements for determining the safety and efficacy of cannabinoids for the management of pain.
  • It’s unclear whether kratom has an effect on chronic pain because of a lack of studies of this substance in people.
  • There’s a lack of high-quality research to definitively evaluate whether Reiki is of value for pain relief.
  • Although static magnets are widely marketed for pain control, the evidence does not support their use.

What the Science Says About Safety and Side Effects

As with any treatment, it’s important to consider safety before using complementary health approaches. Safety depends on the specific approach and on the health of the person using it. If you’re considering or using a complementary approach for pain, check with your health care providers to make sure it’s safe for you.

Safety of Psychological and Physical Approaches

  • Psychological approaches (such as mindfulness/meditation, hypnosis, relaxation techniques), physical approaches (such as acupuncture, massage therapy, spinal manipulation), and the combination of psychological and physical approaches (such as tai chi, qigong, and yoga), are generally safe for healthy people if they’re performed appropriately.
    • People with medical conditions and pregnant women may need to modify or avoid some complementary health approaches.
    • Like other forms of exercise, complementary health approaches that involve movement, such as tai chi and yoga, can cause sore muscles and may involve some risk of injury.
    • It’s important for practitioners and teachers of these approaches to be properly qualified and to follow appropriate safety precautions.
  • See the Health Topics A–Z list on the NCCIH website for resources about specific complementary health approaches, including information about their safety.

Safety of Nutritional Approaches

  • "Natural” doesn’t always mean “safe.” Some nutritional approaches such as dietary supplements may have side effects and may interact with medications.
  • The FDA has warned the public about several dietary supplements promoted for arthritis or pain that were tainted with prescription drugs.
  • See the Health Topics A–Z list on the NCCIH website for resources about specific nutritional approaches, including information about their safety. For information on dietary supplements in general, see NCCIH’s webpage Dietary and Herbal Supplements.

For more information on complementary health approaches that have been studied for pain, see:

Guidelines for the Treatment of Chronic Pain Conditions

National health professional organizations have issued guidelines for treating several chronic pain conditions. Some mention ways in which certain complementary health approaches can be incorporated into treatment plans. Others discourage the use of certain complementary approaches.

A clinical practice guideline from the American College of Physicians encourages the use of nonpharmacologic approaches as initial treatment for chronic low-back pain. The options they suggest include several complementary approaches—acupuncture, mindfulness-based stress reduction, tai chi, yoga, progressive relaxation, biofeedback, and spinal manipulation—as well as conventional methods such as exercise and cognitive behavioral therapy.

The American College of Rheumatology mentions several complementary approaches in its guidelines for the management of osteoarthritis of the hip or knee. For osteoarthritis of the knee, the guidelines mention tai chi as one of several nondrug approaches that might be helpful. The same guidelines, however, discourage using the dietary supplements glucosamine and chondroitin for osteoarthritis of the hip or knee.

The American College of Gastroenterology (ACG) included probiotics/prebiotics, peppermint oil, and hypnotherapy in its evaluation of approaches for managing irritable bowel syndrome. The ACG found only weak evidence that any of these approaches may be helpful.

For more information, see NCCIH’s webpage Pain Information for Health Professionals.

NCCIH-Funded Research

NCCIH is part of the National Institutes of Health (NIH) Pain Consortium, which coordinates pain research across NIH. NCCIH-supported studies are helping to build an evidence base on the effectiveness and safety of complementary modalities for treating chronic pain.

NCCIH is also the lead agency in the Pain Management Collaboratory, an initiative jointly supported by NIH, the Department of Defense, and the Department of Veterans Affairs. The goal of the collaboratory is to develop the capacity to implement cost-effective large-scale pragmatic clinical research in military and veteran health care delivery organizations focusing on nonpharmacologic approaches to pain and other conditions that may occur along with it.

More about NCCIH-funded pain research

NCCIH-supported studies in progress are investigating a variety of topics related to chronic pain, including the following:

  • Whether tai chi is helpful for chronic low-back pain in older adults
  • The potential value of probiotics for relieving pelvic pain associated with interstitial cystitis/bladder pain syndrome
  • Whether progressive muscle relaxation is helpful for patients who visit emergency departments because of migraine
  • The relationship between the availability of chiropractic care and the use of health services for back pain by older adults.

NCCIH’s Division of Intramural Research conducts research focusing on the role of the brain in perceiving, modifying, and managing pain. Research topics include investigating the role of the brain in pain processing and control, and how factors such as emotion, attention, environment, and genetics affect pain perception.

In light of the human and economic costs of chronic pain, as well as evidence that many people who have chronic pain turn to complementary health approaches for relief, NCCIH places a high priority on pain-related research. Researchers in this area face unique challenges: much remains to be understood about the nature of chronic pain and about the best ways of studying its many causes, people’s different responses, and the value of various treatment approaches—complementary and conventional. The ultimate goal is to build an evidence base that can guide pain management decisions tailored to individuals. These decisions often involve combining treatment approaches in cost-effective ways that do the best possible job of helping people minimize pain, carry out everyday activities, and improve their quality of life.

While building an evidence base to help people with chronic pain and their health care providers make decisions about pain management, research on complementary health approaches is also helping to close gaps in our basic understanding of pain mechanisms.

If You Are Considering Complementary Health Approaches for Chronic Pain

  • Don’t use an unproven product or practice to postpone seeing a health care provider about chronic pain or any other health problem.
  • Learn about the product or practice you are considering, especially the scientific evidence on its safety and whether it works.
  • Talk with the health care providers you see for chronic pain. Tell them about the product or practice you’re considering and ask any questions you may have. They may be able to advise you on its safety, use, and likely effectiveness.
  • If you’re considering a practitioner-provided complementary health approach such as spinal manipulation, massage, or acupuncture, ask a trusted source (such as your health care provider or a nearby hospital) to recommend a practitioner. Find out about the training and experience of any practitioner you’re considering. Ask whether the practitioner has experience working with your pain condition.
  • If you’re considering dietary supplements, keep in mind that they can cause health problems if not used correctly, and some may interact with prescription or nonprescription medications or other dietary supplements. Your health care provider can advise you. If you’re pregnant or nursing a child, or if you’re considering giving a child a dietary supplement, it’s especially important to consult your (or the child’s) health care provider. To learn more, visit NCCIH’s webpage on dietary supplements.

1Certain chronic conditions, several of which cause pain, may occur together; some individuals have two or more of these problems. These conditions include chronic fatigue syndrome, endometriosis, fibromyalgia, interstitial cystitis (painful bladder syndrome), irritable bowel syndrome, temporomandibular joint dysfunction, and vulvodynia (chronic vulvar pain). It is not known whether these disorders share a common cause.

For More Information

NCCIH Clearinghouse

The NCCIH Clearinghouse provides information on NCCIH and complementary and integrative health approaches, including publications and searches of Federal databases of scientific and medical literature. The Clearinghouse does not provide medical advice, treatment recommendations, or referrals to practitioners.

Toll-free in the U.S.: 1-888-644-6226

Telecommunications relay service (TRS): 7-1-1

Website: https://nccih.nih.gov/

Email: [email protected] (link sends email)

National Institute of Neurological Disorders and Stroke (NINDS)

NINDS conducts and supports research on how the brain and nervous system function and on treatments for neurological diseases.

Toll-free in the U.S.: 1-800-352-9424

Website: https://www.ninds.nih.gov

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

The mission of NIAMS is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases.

Toll-free in the U.S.: 1-877-22-NIAMS

Website: https://www.niams.nih.gov

Know the Science

NCCIH and the National Institutes of Health (NIH) provide tools to help you understand the basics and terminology of scientific research so you can make well-informed decisions about your health. Know the Science features a variety of materials, including interactive modules, quizzes, and videos, as well as links to informative content from Federal resources designed to help consumers make sense of health information.

Explaining How Research Works (NIH)

Know the Science: 9 Questions To Help You Make Sense of Health Research

Understanding Clinical Studies (NIH)

PubMed®

A service of the National Library of Medicine, PubMed® contains publication information and (in most cases) brief summaries of articles from scientific and medical journals. For guidance from NCCIH on using PubMed, see How To Find Information About Complementary Health Approaches on PubMed.

Complementary Health Approaches for Chronic Pain—Randomized Controlled Trials

Website: https://pubmed.ncbi.nlm.nih.gov/

Cochrane Database of Systematic Reviews

The Cochrane Database of Systematic Reviews is a collection of evidence-based reviews produced by the Cochrane Library, an international nonprofit organization. The reviews summarize the results of clinical trials on health care interventions. Summaries are free; full-text reviews are by subscription only.

Website: https://www.cochranelibrary.com/

NIH Clinical Research Trials and You

The National Institutes of Health (NIH) has created a website, NIH Clinical Research Trials and You, to help people learn about clinical trials, why they matter, and how to participate. The site includes questions and answers about clinical trials, guidance on how to find clinical trials through ClinicalTrials.gov and other resources, and stories about the personal experiences of clinical trial participants. Clinical trials are necessary to find better ways to prevent, diagnose, and treat diseases.

Website: https://www.nih.gov/health-information/nih-clinical-research-trials-you

MedlinePlus

To provide resources that help answer health questions, MedlinePlus (a service of the National Library of Medicine) brings together authoritative information from the National Institutes of Health as well as other Government agencies and health-related organizations.

Information on chronic pain

Website: https://www.medlineplus.gov/

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Acknowledgments

NCCIH thanks David Shurtleff, Ph.D., NCCIH, for his review of the 2018 update of this publication.

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Last Updated: September 2018