Pain isn’t what you think: Why it hurts, why it lingers, and why you’re not imagining it

Pain is something most people only stop to think about when it strikes. When it does, the instinct is simple: make it stop, as fast as possible. But new research suggests pain is far more complex than many of us have been led to believe.

That’s the focus of a public lecture titled 'Why does that hurt? What we know and don’t know about how pain emerges and persists', to be presented as part of the Summer School programme hosted by the University of Cape Town Neuroscience Institute.

Associate Professor Tory Madden, from the African Pain Research Initiative, says one of the biggest misconceptions about pain is that it directly reflects injury.

Pain as an alarm, not a damage meter

“Pain is more like an alarm system,” Madden explains. “It’s designed to protect us, not to give an accurate readout of tissue damage.”

That’s why you can feel pain before any actual harm occurs.

Touch a hot stove, and your hand pulls away almost instantly – often before the skin is damaged. The pain comes first, as a warning.

Crucially, this system prioritises protection over precision. And that means it sometimes overreacts.

Why pain can persist without injury

Research now shows that pain is shaped by far more than signals from injured tissue. Context matters. Past experiences matter. Stress, fear, memories, beliefs and messages from others all feed into how the nervous system decides whether a body part is under threat.

In some cases, the system becomes hypersensitive – generating pain even when tissue is no longer damaged or never was.

“That doesn’t mean the pain isn’t real,” Madden stresses. “It means the system is being overprotective.”

Rethinking ‘pain tolerance’

The idea that some people simply have a ‘high pain threshold’ is also misleading.

Pain tolerance fluctuates constantly, even within the same person.

“You can experience the same stimulus very differently on different days,” says Madden. “That tells us pain thresholds are not fixed.”

This helps explain why pain can feel overwhelming at one moment and manageable at another – without any change in physical injury.

A shift that matters for patients

This evolving understanding has major implications for people living with persistent pain conditions, including fibromyalgia and chronic back pain; groups that have often been dismissed or told their symptoms are ‘all in their head’.

Modern pain science rejects that thinking outright.

“We now know pain is not an accurate marker of damage,” says Madden.

“Chasing tissue injury that isn’t there can actually delay effective care.”

Instead, treatment increasingly focuses on calming an overprotective system and helping patients understand what’s driving their pain – a shift many describe as life-changing.

Is the medical world catching up?

While pain science has moved rapidly, clinical practice hasn’t always kept pace. Some clinicians are still trained to see pain purely as a sign of physical damage.

But that is starting to change, with new training initiatives and growing efforts to update medical education. Madden says informed patients can also play a role by asking better questions and seeking practitioners who take a modern, patient-centred approach.

Her Summer School lecture, along with a follow-up panel discussion later in the week, aims to give people the tools to do exactly that.

For anyone approaching surgery, living with unexplained pain, or simply wondering why pain so often ‘doesn’t make sense’, the message is clear: your pain is real – and science is finally catching up.

For more information, listen to Madden using the audio player below.