Chronic primary and secondary pain in children: Case

Framing the case

This thirteen-year-old has the classic shape of chronic primary pain in an adolescent: widespread pain for more than three months, fatigue and unrefreshing sleep, difficulty concentrating, fluctuating and migrating pain, declining school attendance, and a folder of normal tests. The framework that organises the case is the ICD-11 split of chronic pain into primary, where the pain is itself a nociplastic disease of a sensitised nervous system, and secondary, where the pain arises from an identifiable cause. This girl sits firmly in chronic primary pain, ICD-11 code MG30.0, and the priority is not another scan or a stronger analgesic but a biopsychosocial explanation and an interdisciplinary rehabilitation plan. [1][2]

The biopsychosocial assessment and the red-flag screen

The assessment is a biopsychosocial history more than a physical hunt. Cover seven domains: the pain itself and its fluctuating, migrating course; the mood and anxiety, which here include low mood and withdrawal; the sleep, which is broken and unrefreshing; the school attendance, now two days a week; the family response, with a parent pressing for more investigation; the prior tests and treatments; and the girl's own understanding and goals. Examine to screen for the serious mimics and to demonstrate a thorough examination: growth and pubertal staging, a full musculoskeletal screen for joint swelling, warmth, range and gait, and a neurological screen. Quantify function with a numeric pain scale, a Functional Disability Inventory, a pain and sleep diary, and a direct count of school days missed. [7]

The mechanism explained to the family

The piece of the case that does the most therapeutic work is the explanation. Chronic primary pain is nociplastic: after prolonged nociceptive input, the spinal cord and brain become sensitised, the threshold for pain drops, and pain is generated with less input and persists without tissue damage. This is why the pain is widespread and migrates, and why the scans are normal. The normal scan is not a contradiction of the pain; it is the expected finding in a sensitised nervous system, and it is the evidence that there is no dangerous disease. The behavioural counterpart is the fear-avoidance cycle: the girl interprets pain as damage, avoids movement, becomes deconditioned, and hurts more when she moves, which confirms the belief that movement is dangerous. [1][7]

The interdisciplinary rehabilitation plan

The plan is built with a paediatrician, a psychologist, a physiotherapist and a nurse or social worker, with the school and the family engaged. The goal is stated up front and returned to often: restored function, sleep, mood, school attendance and participation. Pain may persist, but life comes back, and a pain score of zero is not the goal. [7]

The three pillars are as follows. Physical reactivation is the engine: graded, paced activity increased on a fixed schedule regardless of pain, a sleep and routine plan with consistent sleep and wake times, and a staged return to school beginning with partial days and building up. Psychological therapy is the best-evidenced intervention: cognitive behavioural therapy or acceptance and commitment therapy addresses fear-avoidance, catastrophising, low mood and anxiety, with parent-focused strategies to reduce over-protection. Pharmacology has a limited, mechanism-based role: short-term paracetamol or a non-steroidal anti-inflammatory for a genuine nociceptive flare, and a gabapentinoid or tricyclic for any neuropathic component, but nociplastic pain responds poorly to analgesics and they should not become the centrepiece. [7][9]

The opioid-sparing counselling

The mother's request for stronger painkillers is the moment of greatest leverage. Opioids are not recommended for chronic primary, non-cancer pain in children: the WHO 2020 guidelines on the management of chronic pain in children do not recommend initiating strong opioids for chronic primary pain, the evidence for efficacy is absent, and the harms include dependence, adverse effects and lost function. The request is reframed, with full validation that the pain is real, into the recovery plan of movement, sleep, mood and school. If she were already on an opioid prescribed elsewhere, the plan would include a careful, supervised deprescribing strategy as part of rehabilitation. [7]

Prognosis, disposition and the safety-net

Chronic primary pain in children is treatable, and many improve substantially with an interdisciplinary approach, though complete pain elimination is uncommon and should not be promised. The strongest predictor of persistence is ongoing disability and untreated mood and anxiety, which is precisely why function is treated as the outcome that matters. Most children with mild to moderate pain are managed in primary or general paediatric care; referral to a specialist paediatric chronic pain service is indicated when the pain is severe, when disability is significant, or when initial management has not worked. This girl, with two days of school a week and profound disability, warrants referral to a specialist paediatric chronic pain service or an intensive interdisciplinary programme. The safety-net is explicit: the family is taught the red flags that would warrant urgent review, and a scheduled follow-up reviews function and adjusts the plan. [7][11]

The single framework that carries the case

Chronic pain in a child is pain lasting more than three months. Chronic primary pain is nociplastic, driven by central sensitisation, with distress and disability and no better explanation. The job is to screen once for red flags, avoid over-investigation and opioids, explain pain as a wound-up nervous system, and build an interdisciplinary rehabilitation plan that restores function, sleep, mood and school. That one framework carries the whole case from the outpatient clinic to the recovery. [1][7]