Pain history and symptoms

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

History and Symptoms

The McGill Pain Questionnaire is available.[1]


Pain may range in intensity from slight through severe to agonizing and can appear as constant or intermittent. The threshold of pain varies widely between individuals. Many attempts have been made to create a pain scale that can be used to quantify pain, for instance on a numeric scale that ranges from 0 to 10 points. In this scale, zero would be no pain at all and ten would be the worst pain imaginable. The purpose of these scales is to monitor an individual's pain over time, allowing care-givers to see how a patient responds to therapy for example. Accurate quantification can also allow researchers to compare results between groups of patients.

Asking pain tolerability may be helpful[2].


Pains are usually called according to their subjective localization in a specific area or region of the body: headache, toothache, shoulder pain, abdominal pain, back pain, joint pain, myalgia, etc. Localization is not always accurate in defining the problematic area, although it will often help narrow the diagnostic possibilities. Some pain sensations may be diffuse (radiating) or referred. Radiation of painoccurs in neuralgia when stimulus of a nerve at one site is perceived as pain in the sensory distribution of that nerve. Sciatica, for instance, involves pain running down the back of the buttock, leg and bottom of foot that results from compression of a nerve root in the lumbar spine. Referred pain usually happens when sensory fibres from the viscera enter the same segment of the spinal cord as somatic nerves i.e. those from superficial tissues. The sensory nerve from the viscera stimulates the nearby somatic nerve so that the pain localization in the brain is confused. A well-known example is when the pain of a heart attack is felt in the left arm rather than in the chest.[3]

Nurses use the PQRST method to qualify the pain

P = provocation / palliation : what were you doing when the pain started? What caused it? What makes it better? worse? What seems to trigger it? Stress? Position? Certain activities? Arguments? Does it seem to be getting better, or getting worse, or does it remain the same? What relieves it: changing diet? changing position? taking medications? being active? resting? What makes (the problem) worse?

Q = quality / quantity : What does it feel like? Is it sharp? Dull? Stabbing? Burning? Crushing? throbbing? nauseating? shooting? twisting? stretching? Other? (The person who is suffering the pain should describe the pain, rather than saying what they think you would like to hear.) How does it feel, look or sound? How much of it is there?

R = region / radiation : Where is the pain located? Does the pain radiate (i.e. spread to another location, eg. pain source is from thumb but pain spreads to elbow)? Where does it radiate? Is it all in one place? Does it go anywhere else? Did it start elsewhere and now localised to one spot? Does it feel like it travels/moves around?

S = severity scale : How severe is the pain on a scale of 0 - 10, zero being no pain at all and 10 being the worst pain ever? Does it interfere with activities? How bad is it when it's at its worst? Does it force you to sit down, lie down, slow down? How long does an episode last?

T = timing : When did the pain start, at what time? How long did it last? How often does it occur? Is it sudden or gradual? What were you doing when you first experienced or noticed it? How often do you experience it: hourly? daily? weekly? monthly? When do you usually experience it: daytime? night? in the early morning? Are you ever awakened by it? Does it lead to anything else? Is it accompanied by other signs and symptoms? Does it ever occur before, during or after meals? Does it occur seasonally?

Other questions to ask when assessing a person in pain:

  • Any medication or allergies?
  • Does it hurt on deep inspiration?
  • Activity at onset?
  • Any history of pain?
  • Is it the same?
  • Different?
  • Any family history of heart disease, lung problems, diabetes, stroke, hypertension?
  • Check LOC
  • Pupils?
  • JVD?
  • Midline trachea?
  • Any recent trauma?

The purpose for these questions are to be as specific as possible in the description of the pain : when and where, what it feels like... The more specific and detailed information, the better it will be to diagnose the problem/cause and find a way to alleviate it.


Brief Pain Inventory

The Brief Pain Inventory (BPI) may be better than simply asking if someone is in pain.[4]

Visual analog scale (VAS)

The visual analog scale (VAS) may be used to measure agreement between two methods to rate pain[5][6].

The VAS also leads to measuring the area under curve over a time period such as 0-72 hours (AUC0-72h)[7]. This can be done with the method of Huskisson[8], with anchors at 0 = 'No pain' and 100 = 'Unbearable pain'.

Minimally important difference

In assessing the effectiveness of treatments to reduce pain, the minimally important difference in pain is an important measure[9]. Suggestions for this threshold include:

  • 50% reduction in pain[9]
  • Reduction to < 4 on a 10-point scale[9]
  • Absolute reduction of 2 or more on a 10-point scale[9]
  • Absolute reductions of 8 to 40 mm (standardized to a 100 mm scale) and the relative MCID values from 13% to 85%[10]
  • Relative relative reductions of 13% to 85% (standardized to a 100 mm scale)[10]
  • "For chronic back pain, a change of about 20% and for acute pain a change of approximately 12%, is regarded to be clinically significant"[11]


  1. Melzack R (2005). "The McGill pain questionnaire: from description to measurement". Anesthesiology. 103 (1): 199–202. PMID 15983473.
  2. Markman JD, Gewandter JS, Frazer ME (2020). "Comparison of a Pain Tolerability Question With the Numeric Rating Scale for Assessment of Self-reported Chronic Pain". JAMA Netw Open. 3 (4): e203155. doi:10.1001/jamanetworkopen.2020.3155. PMC 7171555 Check |pmc= value (help). PMID 32310281 Check |pmid= value (help).
  3. Other examples include headache while eating ice cream, toothache resulting from a strained upper back, foot soreness caused by a tumor in the uterus, and hip discomfort when the problem is really arthritis in the knee. These examples are taken from Nerves Tangle, and Back Pain Becomes a Toothache, by Kate Murphy, The New York Times, September 16, 2008.
  4. Dennis BB, Bawor M, Paul J, Plater C, Pare G, Worster A; et al. (2016). "Pain and Opioid Addiction: A Systematic Review and Evaluation of Pain Measurement in Patients with Opioid Dependence on Methadone Maintenance Treatment". Curr Drug Abuse Rev. 9 (1): 49–60. PMID 27021147.
  5. Myles PS, Myles DB, Galagher W, Boyd D, Chew C, MacDonald N; et al. (2017). "Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state". Br J Anaesth. 118 (3): 424–429. doi:10.1093/bja/aew466. PMID 28186223.
  6. Ham OK, Kang Y, Teng H, Lee Y, Im EO (2015). "Consistency and Accuracy of Multiple Pain Scales Measured in Cancer Patients From Multiple Ethnic Groups". Cancer Nurs. 38 (4): 305–11. doi:10.1097/NCC.0000000000000179. PMC 4305507. PMID 25068188.
  7. A randomised, double-blind, multi-centre, placebo controlled parallel group study to evaluate the efficacy and tolerability of a new Ibuprofen patch in patients with acute sports related traumatic blunt soft tissue injury/contusion to the upper or lower limbs. Available at
  8. Scott J, Huskisson EC (1976). "Graphic representation of pain". Pain. 2 (2): 175–84. PMID 1026900.
  9. 9.0 9.1 9.2 9.3 Maxwell LJ, Wells GA, Simon LS, Conaghan PG, Grosskleg S, Scrivens K; et al. (2015). "Current State of Reporting Pain Outcomes in Cochrane Reviews of Chronic Musculoskeletal Pain Conditions and Considerations for an OMERACT Research Agenda". J Rheumatol. 42 (10): 1934–1942. doi:10.3899/jrheum.141423. PMC 6649665 Check |pmc= value (help). PMID 26373562.
  10. 10.0 10.1 Olsen MF, Bjerre E, Hansen MD, Hilden J, Landler NE, Tendal B; et al. (2017). "Pain relief that matters to patients: systematic review of empirical studies assessing the minimum clinically important difference in acute pain". BMC Med. 15 (1): 35. doi:10.1186/s12916-016-0775-3. PMC 5317055. PMID 28215182.
  11. Haefeli M, Elfering A (2006). "Pain assessment". Eur Spine J. 15 Suppl 1: S17–24. doi:10.1007/s00586-005-1044-x. PMC 3454549. PMID 16320034.

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