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“Primary” versus “functional” pain

Paul Ingraham ARCHIVEDMicroblog posts are archived and rarely updated. In contrast, most long-form articles on PainScience.com are updated regularly over the years (see updates page).

A “primary” headache is basically an unexplained headache: a headache without an obvious cause. The headache is the main thing, not a symptom of some other thing we know about.

Primary is standard terminology and (appropriately) emotional neutral.

Weirdly, unexplained primary pain problems in other parts of the body are often called “functional pain disorders” … and this term is not neutral. In fact, it’s kind of an asshole of a term with a lot of shameful historical baggage. If terms were people, this one would be your racist uncle.

Originally tamer, over the last several decades “functional pain” gradually became obnoxious doctor-code for “probably psychosomatic”: because if we don’t know how to explain it, it must be all in your head, right? Obviously! This classic argumentum ad ignorantiam — argument from ignorance — got enshrined in jargon and became one of the great shames of medicine. It really needs to go away.

It’s nice that primary headache has mostly escaped the stink of the “functional” label, but diseases like fibromyalgia and irritable bowel syndrome are hopelessly mired in it. They should also be called “primary pain” problems, I believe. Primary headaches are mostly thought of as legitimately unexplained, with much less judgement.

Why would that be? Probably because unexplained headaches are so common that they frequently afflict the self-same doctors that would otherwise get condescending and dismissive! And so, although primary headaches are often considered an example of a “functional pain disorder,” they are rarely called that.

Unexplained headache free of judgemental baggage? Surely you jest!

Some readers are now hollering at the screen:

Are you *#%[email protected]^% kidding me? I had a neurologist tell me that I have migraines because I’m an excessively ‘willful’ woman! Right to my face! In 2019!

That diagnostic crime isn’t yet extinct. Headache/migraine obviously haven’t entirely avoided the same stigma suffered by other primary pain disorders. While it’s refreshing that the term “functional” is applied to headaches less often, the diagnostic buck has been passed to psychiatrists all too often, especially for migraine. You can bet that many female migraineurs throughout history have been told they were “hysterical,” and that is appalling.

This is an excerpt from a recent update to my headache tutorial, and it continues with a discussion of the role of the mind and stress in headache. I’ve also updated my article about types of pain with “functional pain.”

 End of post. 
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