Chronic pain is among the most common reasons adults seek medical care. According to a 2016 study by the US Centers of Disease Control and Prevention, an estimated 20.4% of US adults live with chronic pain. Some studies report that chronic pain affects more than 30% of the global population and remains a leading cause of disability. Chronic widespread pain is also associated with increased mortality, potentially due to a combination of decreased physical activity, poor diet quality, smoking, and higher rates of depression and anxiety.

A multifaceted, multidisciplinary approach is well established as the most effective strategy for relieving pain, improving function, and enhancing quality of life. However, certain populations are more vulnerable to chronic pain and may face limitations in available treatments, particularly pharmacologic options. This article discusses pediatric, geriatric, and pregnant populations, highlighting common pain syndromes and unique considerations for their management.

Chronic pain during childhood is linked to substantial functional impairment, which frequently persists in adulthood. Children who experience chronic pain are at risk for several comorbidities, including anxiety and depression, and are at risk of social isolation and school absences. A 2024 systematic review and meta-analysis by Chambers and colleagues noted the prevalence of chronic pain in children and adolescents at 20.8%, which is equal if not slightly higher than the prevalence reported in adults. The authors found that the highest prevalence or chronic pain in children and adolescents was for headache and musculoskeletal (MSK) pain, and that girls had a higher prevalence of most types of pain than boys. In 2016, it was reported that moderate to severe pain in children costs $19.5 billion in the United States alone. Given these findings, early diagnosis and treatment of chronic pain in children and adolescents is essential. The Pediatric Pain Screening Tool (PPST) is a 9 item questionnaire to efficiently address physical and psychosocial symptoms in youth with chronic pain. It helps determine a patient’s risk of poor pain-related outcomes and includes 2 subscales. The physical subscale has 4 items that assess comorbid pain, ambulation, school attendance, and sleep. The psychosocial subscale includes 5 items assessing pain catastrophizing, pain-related fear, generalized anxiety, depression, and pain bothersomeness. Total scores range from 0 to 9. Low risk is defined as a total score of 0 to 2, high risk as a psychosocial subscale score of 3 or more, and medium risk as a total score of 3 or more with a psychosocial score of 0 to 2. The PPST’s sensitivity and specificity range from adequate to excellent regarding significant disability and emotional distress. It is a useful tool for identifying high-risk youth and guiding treatment decisions.

The biopsychosocial model is essential to understanding chronic pain in children. It reflects the complex interplay between pain and psychological, social, and environmental influences. Anxiety, peer relationships, and parental behavior can all contribute to the pain experience and coping mechanisms. Anxiety and depression may develop when children are unable to engage in normal activities, such as sports or extracurriculars, leading to loneliness and reduced self-esteem. Similarly, absences from school due to pain may increase anxiety related to returning to school. Children who have family members, specifically parents, that also suffer from chronic pain may learn coping mechanisms for their pain, which may be maladaptive. Parents’ reactions to their child’s pain may also lead to maladaptive coping. A 2014 study demonstrated that parental pain and catastrophizing were associated with adolescent pain, somatic symptoms, and disability. Parent catastrophizing was a significant predictor of adolescent somatic symptoms and pain-related disability beyond the influence of parent pain alone.

Primary pain disorder describes chronic pain that cannot be explained by medical evaluation but still significantly disrupts a child’s life. Common types of primary pain in children and adolescents include headache/migraine, abdominal pain, and MSK pain. Effective treatment typically involves a multidisciplinary approach, as shown in Fig. 1 .

Effective treatment typically involves a multidisciplinary approach.

( From Collins AB. Chronic Pain in Children: Interdisciplinary Management. Pediatr Clin North Am 2023;70(3):575–588. https://doi.org/10.1016/j.pcl.2023.01.010 , with permission.)

The prevalence of migraine in children and adolescents is approximately 8%, and studies show that the quality of life for children with migraine is comparable to that of children with diabetes, arthritis, or cancer. About half of these children will continue to experience migraines into adulthood. Barmherzing and colleagues emphasize the importance of “headache hygiene” which includes self-management strategies to reduce headache frequency and disability. One key element of headache hygiene is patient education. Although stress, sleep deprivation, and environmental factors are often cited as headache triggers, evidence supporting these associations is weak, and caution should be used in counseling families to avoid creating unnecessarily restrictive lifestyles. ^, Medication overuse can also worsen headaches. In fact, it is estimated that about 50% of children and adolescents with chronic migraines overuse acute medications. Providers should advise caution regarding the overuse of analgesics as a primary means for controlling acute headache and migraine.

Lifestyle factors such as low physical activity, smoking, caffeine intake, and obesity have been linked to increased migraine prevalence. Adolescents who adopt healthy habits, such as regular aerobic exercise, good sleep hygiene, and adequate hydration, may experience fewer and less severe headaches. These recommendations form the second part of Barmherzig’s headache hygiene triad. The third component of the triad is psychological intervention. Techniques like cognitive behavioral therapy (CBT), biofeedback, relaxation strategies, and mindfulness can be highly beneficial. ^, A 2014 meta-analysis found that psychological therapies were beneficial in reducing disability in children with chronic headache, including migraine, and those results were sustained at follow-up. The American Academy of Neurology as well as the American Headache Society recommend combining pharmacologic treatment with behavioral therapy, based on a large randomized controlled trial demonstrating superior outcomes from integrated care.

From a pharmacologic standpoint, acute headache management is typically treated with medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, triptans, and ergotamines. To prevent medication overuse headaches, current recommendation for medications such as NSAIDs and acetaminophen is to avoid using more than 3 days per week or greater than 15 days per month. For those using medications such as opioids, ergotamines, triptans, combination analgesics, or medications from multiple classes, the recommendation is to avoid using those medications more than 2 days per week or greater than 10 days per month. For migraine prevention, medications such as tricyclic antidepressants, antiepileptics, beta blockers, and calcium channel blockers are commonly used. Amitriptyline is typically used as first-line treatment for migraine prevention.

Just as headaches represent a frequent source of recurrent pain in children and adolescents, gastrointestinal complaints are another common presentation. Functional gastrointestinal disorders (FGIDs) are characterized by persistent gastrointestinal symptoms without identifiable structural or biochemical abnormalities. The Rome IV criteria describe 4 conditions that primarily present with pain—functional dyspepsia, irritable bowel syndrome, abdominal migraine, and functional abdominal pain, not otherwise specified. FGID can also manifest as conditions that present primarily with nausea and vomiting, as well as defecation dysfunction; however, for the purpose of this article the focus will be on pain disorders. Approximately 10% of children present to clinicians with chronic abdominal pain. A 2015 meta-analysis described the worldwide prevalence of abdominal pain-predominant FGID in children at 13.5%, with irritable bowel syndrome (IBS) being the most common. Typically, a diagnosis of FGID is made before a patient presents to a chronic pain clinic, but understanding the distinguishing features of each condition remains essential for guiding management. While all share the common thread of recurrent abdominal pain, the pattern and triggers vary. In IBS, pain typically improves after defecation. Pain from functional dyspepsia typically worsens after eating. Abdominal migraine may present as intense pain lasting for 1 to 2 days, with symptom-free intervals in between. Functional abdominal pain, not otherwise specified, may manifest as daily, constant pain unrelated to meals or bowel movements. ^,

The management of FGID follows the biopsychosocial model. The principles of management are outlined in Box 1 . Education is critical, for both the child and family, to convey the benign nature of the condition while validating the impact of symptoms. Despite normal physical examinations and test results, symptoms can be disruptive and distressing. Treatment goals include restoring function and daily activity, rather than solely eliminating pain.

Dietary interventions can be helpful if specific food triggers are identified. Common precipitants include lactose, fructose, caffeine, spicy foods, fatty or greasy foods, carbonated drinks, large meals, and gas-producing vegetables. If certain foods or beverages are found to exacerbate a child’s symptoms, avoidance or elimination of these items may be a reasonable approach. A 2022 systematic review and meta-analysis found no high-quality evidence to recommend a specific diet but noted that fiber may be useful due to favorable outcomes and minimal side effects. Similar results are shown with regard to pharmacologic interventions. A 2021 systematic review evaluated evidence for antispasmodics, antidepressants, antibiotics, antihistaminic, antiemetic, histamine-2-receptor antagonist, 5-HT4-receptor agonist, melatonin, and buspirone. While no single pharmacologic agent could be universally recommended due to low-quality evidence, antispasmodics and antidepressants showed some benefit with low side effect profiles. There is evidence supporting cognitive behavioral therapy and biofeedback for symptom improvement for children with chronic abdominal pain, and it can improve social functioning and school attendance. A randomized controlled trial showed that 60% of children with chronic abdominal pain who underwent cognitive behavioral therapy had significant improvement in symptoms.

Chambers and colleagues reported that among children and adolescents with chronic pain, approximately 25% experience primarily MSK pain and around 20% report back pain. The most common forms of noninflammatory chronic MSK pain in children and adolescents are amplified MSK pain syndromes, benign limb pain of childhood, benign joint hypermobility syndromes, overuse syndromes, skeletal defects, and back pain. These conditions are consistently associated with decreased health-related quality of life, missed school days, poor sleep, limited social engagement, and elevated rates of anxiety and depression. Amplified MSK pain syndrome can be diffuse, also known as juvenile fibromyalgia syndrome, or localized, also known as complex regional pain syndrome. With proper treatment, prognosis is generally good. Benign limb pain of childhood is described as intermittent bilateral shin, calf, thigh, or posterior knee pain, typically at night. Children who have benign joint hypermobility syndromes can have vague joint pains and significant joint laxity on examination.

The primary treatment goal for chronic MSK pain in children and adolescents is restoration of function. Improving school attendance, physical activity, and participation in daily routines is prioritized, with pain reduction as a secondary outcome. Management should align with the biopsychosocial model, utilizing an interdisciplinary approach that integrates pharmacologic, physical, psychological, and complementary interventions. From a pharmacologic perspective, however, the evidence base in pediatric chronic pain is limited. A 2017 Cochrane Review of NSAIDs for chronic noncancer pain in children found only 7 studies, which was insufficient to perform a meta-analysis, and the overall evidence was low to very low. Several adverse events were also reported. Similarly, evidence supporting other pharmacologic agents, including acetaminophen, opioids, and anti-depressants, remains scarce.

Physical and occupational therapy are core components of care, with therapists playing a central role in building cardiovascular endurance, promoting functional and postural training, and providing education on proper biomechanics. Manual therapy was also found to be beneficial in children with chronic low back pain. Psychological support, particularly CBT, is highly recommended. CBT has been shown to reduce pain intensity and disability immediately after treatment, with effects lasting up to 12 months postintervention.

For children with severe, refractory pain despite outpatient management, intensive interdisciplinary pain treatment may be an option. This is generally defined as an inpatient or daytime hospital treatment program that is typically delivered by at least 3 health care providers. A 2022 systematic review and meta-analysis found that this type of treatment significantly reduced pain intensity, disability, anxiety, and depression in children and adolescents.

As life expectancy continues to rise in the United States, clinicians are increasingly encountering older patients with complex medical needs, including chronic pain. The combination of advancing age, pre-existing comorbidities, and polypharmacy intertwined with chronic degenerative processes makes managing this population challenging. According to the 2020 US Census Bureau, the population of individuals 65 and over accounted for 16.8% of the total population (55.8 million people). This was an overall increase of 38.6% when compared to census numbers from 2010. The change is largely attributed to the aging Baby Boomer cohort who will all be above the age of 65 years by 2030, when the elderly population is projected to make up 20% of the total US population.

Chronic pain is often perceived as an inevitable part of aging, ^,, with 66% of adults aged 65 years and older reporting chronic pain and 70% of older individuals reporting pain at multiple sites. ^, Prevalence is even higher among those with chronic diseases and residents of long-term care facilities. In older adults, chronic pain is associated with reduced mobility, decreased activities of daily living, increased risk of depression and anxiety, cognitive decline, and significant disruption of familial and social relationships. ^,, These complications can also contribute to further medical issues, including deep vein thrombosis, pulmonary embolism, fractures, and a diminished quality of life. Nonetheless, pain in the elderly population is both underreported and undertreated. In a study investigating the prevalence of pain among elderly hospitalized patients, only 49% of individuals experiencing pain received treatment deemed appropriate for the severity of their symptoms, whereas 74.5% of patients regarded the therapy as having low or no effectiveness. Common causes of pain in this population include osteoarthritis, diabetic neuropathy, cancer-related pain, and poststroke pain.

Pain assessment in older adults should begin with a directed medical history and physical examination as multiple sources are common and should be considered. ^, Self-reported pain intensity validated by pain assessment tools continues to be the most accurate and dependable indicator of pain in older adults. ^, Mild to moderate cognitive impairment, as seen in conditions like dementia, generally does not hinder the effectiveness of pain assessment tools in most cases. The most frequently utilized scales in clinical practice include the Numerical Rating Scale (NRS), the Visual Analogue Scale (VAS), and the Verbal Descriptor Scale (VDS). NRS uses an 11 point scale from 0 to 10, with 0 being no pain and 10 being the worst pain possible. VAS utilizes a visual image to help quantify pain but should be used with caution as it has been shown to produce unscorable responses in the elderly. VDS simply uses terms along a scale such as none, mild, moderate, strong, and worst pain possible. A limitation of the VDS is that individuals may interpret the descriptive words differently, making the scale subjective and potentially less accurate for assessing pain.

The American Geriatrics Society and the World Health Organization 3 step analgesic ladder provide structured guidelines for managing pain, tailored to the severity of symptoms. The 3 step pain ladder was originally developed to manage cancer related pain but has now gained widespread acceptance as a framework for guiding analgesic medications. Step 1 includes acetaminophen and NSAIDs for mild pain. Step 2 introduces weak opioids like tramadol for moderate pain, and Step 3 recommends stronger opioids such as morphine or hydromorphone for severe pain. At all stages, co-analgesics (eg, gabapentin) may be added. Incorporating guidelines recommending opioids for management of moderate to severe noncancer pain in older adults has resulted in a significant rise in opioid use over the past decade. ^,, Nearly 70% of nursing home residents with chronic noncancer pain receive scheduled opioids, while 6% to 9% of independently living elderly adults use prescribed opioids. While opioids can reduce pain intensity and improve function, risks include falls, fractures, constipation, cognitive impairment, and addiction. ^,, The decision to initiate opioid therapy should be individualized, taking into account potential drug–drug and drug–disease interactions, the overall risk–benefit profile, and the potential for misuse, diversion, and addiction, which is estimated at 1% to 3%. ^,

In this discussion, the emphasis is on chronic pain management in both inpatient and outpatient settings, as this remains a significant yet often overlooked issue in older adults. Chronic pain in the elderly is often undertreated and underreported. A study examining prevalence, management, intensity, and characteristics of pain of hospitalized patients revealed 23.2% experienced pain. Among those patients with chronic pain, 73.4% did not receive treatment upon admission or at the time of discharge, and 50.5% remained untreated throughout their hospital stay. Another study analyzing nursing home residents revealed 24% of residents reporting pain did not receive pain medication and 11% of the residents who did receive pain medication received it on an as-needed basis. As such, the use of effective pharmacologic treatments is of the utmost importance given the greater prevalence of unrelieved and unrecognized pain.

Another major challenge impacting pain management in the elderly is cognitive impairment resulting in memory, language, and speech deficits limiting clear communication of pain and discomfort. In such cases, the previously mentioned assessment tools (NRS, VAS, and VDS) and collateral information from family or caregivers become even more critical for accurate evaluation. Scheduled, rather than as needed, dosing regimens are recommended for predictably recurrent pain. Literature suggests that low-dose, long-acting opioids may reduce agitation in nursing home patients aged 85 years and older suffering with advanced dementia. Medication titration should remain similar to that for patients with intact cognition- monitoring behavioral, verbal, and functional responses, while monitoring for side effects such as sedation, respiratory depression, cognitive and balance impairment, gastrointestinal bleeding, and constipation. Nonpharmacologic strategies such as exercise, CBT, patient education, heat/cold therapy, and massage can help manage pain, especially when tailored to a patient’s cognitive and functional status. Interventions should be appropriately paced and stimulating to avoid agitation.

As previously discussed, pain treatment is typically divided into nonpharmacologic and pharmacologic approaches. Nonpharmacologic strategies, such as heat and cold therapy, acupuncture, transcutaneous electrical nerve stimulation (TENS), massage, psychological support, and physical therapy show mixed evidence of effectiveness, with limited data specifically in elderly populations. Pharmacologic treatment must account for age-related physiologic changes that affect drug metabolism and response, requiring cautious dosing and selection. A comprehensive discussion for pharmacologic therapies is discussed in another section of this issue. A multimodal, individualized approach is essential for safe and effective pain management in this population and may also include procedural care.

Interventional pain procedures play a unique role in treating chronic pain, offering effective options with fewer systemic side effects compared to pharmacologic therapies. ^, Epidural steroid injections, lumbar facet injections, percutaneous vertebral augmentation, sacroiliac (SI) joint injections, and hip and knee joint injections remain among the most common interventional therapies in the elderly. These options can reduce the need for systemic analgesics and avoid more invasive surgeries. It is important to note the efficacy of these interventions has not been as extensively studied in the elderly; however, risks include complications related to the injection itself, along with comorbidities, anticoagulation status, and steroid use. For high-risk patients, procedures should be performed in hospital settings. ^,

While interventional techniques can address certain aspects of pain, many patients, particularly those with persistent symptoms, require ongoing management beyond the procedural setting. Chronic pain and depression share a bidirectional relationship and are best understood through the biopsychosocial model. ^, Those with greater feelings of hopelessness with respect to their pain experience greater pain intensity, worse overall function, and depression. Psychological management plays a vital role in management of chronic pain. For example, a study found a 1 day perioperative acceptance and commitment workshop resulted in more effective pain reduction 3 months postop, and opioid cessation 9 days earlier.

Taken together, these findings underscore that effective pain management in older adults requires a comprehensive approach—one that integrates accurate assessment, individualized treatment plans, and interdisciplinary collaboration. Nonpharmacologic strategies and interventional techniques offer alternatives to systemic medications and help reduce the risks associated with polypharmacy. A multidisciplinary team can optimize outcomes and enhance quality of life for elderly patients living with chronic pain.