Mild pain that never ends isn’t actually mild

People talk about pain intensity all the time, healthcare professionals ask about it, and studies focus on it. We do our best to quantify it, with mixed results, because the traditional pain scale is a one-dimensional measurement of a multi-dimensional, highly subjective experience — there is no objective pain-meter. There are a lot of reasons why people don’t like to try to put a number on their pain.

But it’s especially odd the way pain is routinely ranked without any curiosity about duration — which is arguably more important than the intensity at any given moment. This is a common complaint about pain care:

“I don’t think I have ever been asked in 20 years about whether my pain is constant, or how long severe pain episodes last for. Only ever asked to score it ‘now’, or a ‘best’ and ‘worst’ in a 2 week period.”

Pain isn’t actually “mild” if it never ends. Persistence can turn even a small pain into a nightmare.

Everyone knows that a toe stub is surprisingly intense, but we also know that the misery is brief. If you had a pain just like that in your noggin, you’d think your head was exploding (an aneurysm). Most headache pain is way less intense than a toe stub, but we also know it’s probably going to last the rest of the day, and most people would prefer the toe stub. Get it over with!

So it’s not that we don’t get this. We talk about it imprecisely and indirectly all the time.

The concept exists in the science. It’s an old tool in analgesic trial methodology — the summed pain intensity difference, or SPID — precisely because trialists realized a snapshot pain score might not capture treatment benefit over time. Used … but only in certain kinds of trials, and debated even there: “SPID does not appear to add anything” (Tfelt-Hansen et al). Just last year Chukka et al set out to “validate SPID’s reliability and clinical utility in orthopaedic surgical cohorts” (and they say they did). And then there are some “competitors” of various types … all barely used.1

So the literature acknowledges the problem and researchers have proposed solutions, but pain-over-time is still mostly missing from most pain research, clinical assessment, and patient communication.2 It’s a good example of what I mean about pain medicine being surprisingly primitive and improvisational.

And it’s weird because describing pain well so clearly involves both intensity and time (among other things, but let’s stay focussed); you truly can’t express the experience of chronic pain when the time thing has been downgraded to a footnote!

For an awful lot of chronic pain patients, being asked mainly about pain intensity is a little awkward — because the reality is that a lot of chronic pain is actually not very intense, and it doesn’t sound so “impressive” when the real story is buried in an addendum: but it never lets up.

Even when the burden over time is substantial, many people won't seek help if the intensity never gets beyond a certain point. Beware of ignoring persistent pain just because it’s mild in any give minute of your day. You might avoid it because you aren't taking it seriously yourself; or you might avoid it because you fear that you won't be taken seriously by healthcare professionals.

The persistence of pain should never be an “asterisk” on your report. As a pain patient, you should not feel like you need a qualifying “but” after giving your pain a number. If the pain intensity alone doesn’t tell the story — and it often doesn’t — then emphasize what does: intensity times duration. When talking to professionals, try to explain how “much” pain there is, and lead with the “area under the curve.”[Wikipedia] Tell them how bothersome it is overall.

If you’re a professional, please make it easy for people: ask about the persistence and pattern of the pain, as well as its intensity. Remember your mnemonics (SOCRATES and OPQRST), and more: take T-for-time seriously! (See footnote #2.)

This post is part of a developing series on pain rating. Previously:

• What are the worst kinds of chronic pain?
• There will never be a pain-o-meter — and maybe that’s a good thing

Notes

1. In 2014, Salamon et al developed a score to "capture pain intensity along with frequency and duration" — the descriptively named pain frequency-severity-duration scale (PFSD).

   In 2016, the National Institute on Drug Abuse developed the Pain Frequency, Intensity, and Burden Scale (P-FIBS).

   In 2020, anaesthesiologists Lang-Illievich et al tackled another method, an "area under the curve" analysis of the graph of pain over time.

   A softer alternative: in 2025, Edwards et al validated single-item "pain bothersomeness" scales — simply asking patients how much their pain bothers them — and showed they outperform intensity-only measures as predictors of functioning, depression, and social outcomes. Bothersomeness doesn't measure time explicitly; instead it asks patients to do the integration themselves. A reasonable workaround, though it obscures rather than illuminates the duration component specifically.

   None of these have seen much (any?) use.

2. Sharp clinicians may be wondering why I would say such a thing when there are well-established mnemonic frameworks that explicitly cover a bunch of factors in assessing pain, including T for time:

   SOCRATES: Site, Onset, Character, Radiation, Associations, Time, Exacerbating/relieving factors, Severity. The T covers timing, duration, pattern, and whether it’s constant or intermittent.

   OPQRST: Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Time. Again, time is explicitly there.

   But there is a huge gap between the ideal and reality, as there so often is in medicine. Many aspirational clinical tools like this are routinely ignored, oversimplified, and sometimes even outright abused in practice. In this case, it’s mostly just neglect. Either clinicians don’t use SOCRATES or OPQRST at all, or it’s token, or muddled, and doesn’t translate into actually weighing time against intensity. A clinician can dutifully note “constant pain for 3 years” and still anchor their severity judgment entirely on an intensity score. To some extent these frameworks may even de-emphasize the time element by reducing it to one checkbox among many. All those factors matter — but intensity×duration burden may be in a class by itself.

   Consider this reader report, demonstrating what I mean:

   “I remember going to a doctor when I had had a headache for months, and they asked me to rate it 0-10 and I said 2. They completely lost interest.” That shouldn’t happen! But it does. And that’s my point.