Last reviewed: 25 Dec 2021
Last updated: 13 Jul 2018



History and exam

Key diagnostic factors

  • presence of risk factors
  • duration of pain more than 3 months
  • physical comorbidity
  • psychological comorbidity
  • previous history of acute pain episodes
  • pain causing difficulty in performing routine activities of daily living
  • precipitating factors for myofascial pain
  • precipitating factors for musculoskeletal pain
  • herpes zoster infection
  • history of trauma or limb immobilisation
  • analgesic use
  • muscle spasm
  • associated somatic symptoms
  • muscle tenderness to palpation
  • trigger-point tenderness
  • taut bands
  • twitch response
  • joint swelling and tenderness
  • tender points

Other diagnostic factors

  • precipitating factors for chronic headache
  • headache pain lasting less than or more than 2 hours
  • radiating pain
  • morning stiffness in joints
  • pain with prolonged walking, relieved with stooping or sitting
  • joint pain
  • burning quality of pain
  • allodynia
  • hyperalgesia
  • chronic headache associated with nausea, vomiting, and sensitivity to light and noise
  • intermittent pattern of chronic headache pain
  • bilateral chronic headache pain
  • unilateral chronic headache pain
  • limited range of motion (ROM)
  • painful or limited straight leg raising
  • shoulder girdle and pelvic girdle pain distribution
  • symmetrical body pain distribution
  • worsening headache symptoms despite treatment
  • headache with posterior head or neck pain
  • excessive guarding of the painful extremity
  • diminution or loss of reflexes
  • tenderness over temporal artery distribution

Risk factors

  • age over 45 years
  • female sex
  • pregnancy
  • history of trauma or chronic pain
  • family history of chronic pain syndromes
  • acute back pain with neurological signs
  • high-risk occupation
  • comorbid personality disorder/psychological distress
  • pain-related disability
  • cigarette smoking

Diagnostic investigations

Investigations to consider

  • plain x-rays of spine, bones, and joints
  • MRI of spine
  • electromyogram and nerve conduction studies

Treatment algorithm



Gaurav Chhabra, MBBS, FRCA, FFPMRCA

Consultant, Pain Medicine and Anaesthesia

North Bristol NHS Trust




GC has been sponsored by Boston Scientific, St Jude Medical, and Nevro to attend cadaveric workshops relevant to neuromodulation.


Dr Gaurav Chhabra would like to gratefully acknowledge Dr Sarah Love-Jones and Dr Dawn A. Marcus, previous contributors to this monograph. SLJ has received consultancy fees for Boston Scientific and Nevro Corporation (regarding spinal cord stimulation) and is an Elected Council member of the British Pain Society. DAM is an author of a reference cited in this monograph.

Peer reviewers

J. David Sinclair, MD

Clinical Instructor

Department of Anesthesiology

University of Washington School of Medicine




JDS declares that he has no competing interests.


Consultant in Pain Management

Pain Unit

King's College Hospital




JH has chaired advisory boards for Napp Pharmaceuticals Ltd., chaired a symposium, is a principle investigator and has participated in advisory boards for Grunenthal Ltd., and has given lectures for Pfizer Ltd. JH has also attended the American Pain Society meeting in 2009 sponsored by Grunenthal.

Beverly J. Collett, MB BS, FRCA, FFPMRCA

Consultant in Pain Medicine

Pain Management Service

University Hospitals of Leicester




Not disclosed.

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