Pain that doesn’t make anatomical sense, pain that spreads beyond the original site, pain that feels “out of proportion” — these are the everyday headaches (and heartaches) for GPs. The culprit behind many of these perplexing presentations? Central sensitisation.
Central sensitisation isn’t just another medical buzzword; it’s a crucial concept that explains why some patients don’t get better despite tissue healing. Recognising it early can change the trajectory from chronic suffering to meaningful recovery.
What is Central Sensitisation?
In simple terms, central sensitisation refers to an amplified pain response driven by changes in the central nervous system (brain and spinal cord). Think of it as a hyperactive alarm system: even minor inputs (or sometimes no obvious inputs at all) can trigger loud, persistent pain signals.
Key features include:
- Increased sensitivity to pain (hyperalgesia)
- Pain in response to normally non-painful stimuli (allodynia)
- Pain spreading beyond the initial area
Unlike nociceptive pain (from actual tissue injury) or neuropathic pain (from nerve damage), central sensitisation involves dysfunction in pain processing rather than ongoing damage.
Why Should GPs Care?
Because central sensitisation is common, under-recognised, and frequently mismanaged. It underpins many chronic pain conditions including:
- Chronic low back pain
- Fibromyalgia
- Chronic headaches and migraines
- Persistent pelvic pain
- Irritable bowel syndrome
- Complex regional pain syndrome
Miss it, and you risk:
- Endless investigations and imaging
- Unnecessary surgeries or interventions
- Escalating opioid use
- Patient frustration and loss of trust
- How to Spot Central Sensitisation in the Clinic
Central sensitisation doesn’t announce itself with a neat label. It demands clinical curiosity and careful questioning.
Clinical clues to watch for:
Pain disproportionate to findings
Patients report severe or widespread pain with minimal or no objective pathology.
Diffuse pain distribution
Pain extends beyond an expected anatomical pattern or dermatomal distribution.
Multiple pain sites
Frequent reports of pain “moving around” or affecting various regions at different times.
Heightened sensitivity
Pain with light touch, mild pressure, or temperature changes (allodynia).
Associated symptoms
Fatigue, poor sleep, cognitive fog (“fibro-fog”), mood disturbances, heightened stress reactivity.
Emotional overlay
Strong fear-avoidance behaviours, catastrophising, or high health anxiety.
Poor response to conventional treatments
Minimal or short-lived benefit from medications, surgeries, or passive therapies.
Simple Screening Tools
If in doubt, consider using brief validated tools:
- Central Sensitisation Inventory (CSI): A questionnaire assessing symptoms related to central sensitisation syndromes.
- PainDETECT or DN4: While primarily neuropathic pain tools, some items hint at central mechanisms.
- Örebro Musculoskeletal Pain Screening Questionnaire: Identifies psychosocial risk factors and potential chronicity.
Talking to Patients About Central Sensitisation
This is where the real art comes in. Avoid saying “It’s all in your head” — the fastest way to lose rapport. Instead, explain that their nervous system has become sensitised, like a car alarm going off too easily.
Example phrasing:
“Your nervous system has become more sensitive over time, so it’s sending strong pain signals even when there’s no new damage.”
“Think of your pain system like a volume dial — in your case, it’s been turned up too high. Our goal is to help turn it back down.”
Reframing pain this way empowers patients and avoids blame.
Management Principles
Central sensitisation requires a multidimensional, biopsychosocial approach:
Education: Pain neuroscience education to demystify and destigmatise symptoms.
Graded activity and exposure: Gentle, progressive reintroduction of movement to avoid deconditioning and fear.
Psychological support: Cognitive behavioural therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based approaches are all effective.
Pharmacological strategies: Medications targeting central mechanisms (e.g., certain antidepressants, anticonvulsants) — but always as part of a broader plan.
Sleep and stress management: Addressing insomnia and stress can significantly modulate central sensitivity.
When to Refer
Consider referring to a pain specialist or multidisciplinary pain service when:
- Pain persists despite first-line biopsychosocial strategies
- Function is severely limited
- Complex psychosocial or psychiatric comorbidities exist
- Diagnostic uncertainty remains
Central sensitisation can feel like a clinical minefield, but with the right approach, it becomes a roadmap for targeted, empathetic care rather than endless diagnostic loops.
GPs and allied health professionals are in the best position to detect it early and intervene before pain becomes a lifelong sentence. Recognising central sensitisation doesn’t mean giving up — it means shifting the game plan from fighting damage to calming the nervous system.
