Types of pain: nociceptive, neuropathic, visceral and referred
- Topic
Pain from injured tissue, from an organ, from a damaged nerve, or felt far from where it starts: each type sounds different when the patient describes it.
See it in 3D: Spinal cord · Diaphragm
What it is
Pain is classified by mechanism. Nociceptive pain comes from activation of pain receptors by tissue injury or inflammation and is either somatic (skin, muscle, bone, joints: well localized) or visceral (organs: deep, vague, often with nausea and sweating). Visceral pain is often referred to a skin area supplied by the same spinal segments. Neuropathic pain comes from damage to the nervous system itself, and nociplastic pain from altered pain processing without clear tissue or nerve damage. Naming the type guides the exam and the treatment.
Key facts
- Allodynia: pain from a stimulus that does not normally hurt, such as clothing or bed sheets touching the skin.
- Hyperalgesia: an exaggerated response to a stimulus that is normally painful.
- Dysesthesia and paresthesia: abnormal sensations such as burning, tingling or 'pins and needles', unpleasant or not.
- Referred pain mechanism: visceral and somatic sensory fibers converge on the same spinal cord neurons, so the brain attributes the pain to the skin area.
- Shift from visceral to somatic pain: early appendicitis is vague and periumbilical, then becomes sharp in the right iliac fossa when the parietal peritoneum is involved.
- Peripheral neuropathic causes: diabetic polyneuropathy, nerve compression, radiculopathy, postherpetic neuralgia; central causes: stroke, spinal cord injury, multiple sclerosis.
Step by step
- Let the patient describe the pain in their own words, then ask them to point to it with one finger or to draw it.
- Ask for its character: sharp, aching, cramping, burning, shooting, electric, pressing.
- Ask what changes it: movement and pressure (somatic), meals or bowel and bladder activity (visceral), touch or cold (neuropathic).
- Look for autonomic signs: nausea, pallor, sweating and restlessness suggest visceral pain.
- Map the area: does it follow a dermatome, a peripheral nerve, a 'glove and stocking' pattern, or is it widespread?
- Examine sensation in the painful area: light touch, pinprick, temperature; look for allodynia and reduced sensation.
- Record intensity with a scale and the effect on sleep, mood and function.
Types of pain and how they present
| Type | How it feels | Example |
|---|---|---|
| Somatic nociceptive | Localized, aching or sharp, worse with movement | Osteoarthritis of the hip |
| Visceral nociceptive | Deep, vague, cramping, with nausea and sweating | Early appendicitis |
| Referred | Felt in a distant skin area of the same segments | Gallbladder pain at the right scapula |
| Peripheral neuropathic, length-dependent | Burning feet in a stocking pattern, numbness | Peripheral neuropathy |
| Neuropathic, cranial nerve | Brief electric shocks in the face, triggered by touch | Trigeminal neuralgia |
| Neuropathic after infection | Burning in a dermatome, before or after a rash | Herpes zoster |
| Nociplastic | Widespread pain, fatigue, poor sleep | Fibromyalgia |
| Regional, with autonomic changes | Pain out of proportion after injury, swelling, color and temperature change | Complex regional pain syndrome |
Clinical notes
- Referred pain can hide an emergency: myocardial infarction felt only in the jaw or arm, or shoulder-tip pain from blood under the diaphragm.
- Visceral pain that becomes localized and sharp signals spread to the parietal peritoneum.
- New neuropathic pain with weakness, saddle numbness or bladder or bowel changes needs urgent assessment of the spinal cord or cauda equina.
- Burning dermatomal pain in an older adult may come days before the herpes zoster rash.
- Pain out of proportion to the exam after a fracture or cast may be compartment syndrome.
In the lab
- The type of pain is a clinical diagnosis from history and examination.
- Screening questionnaires for neuropathic pain, such as DN4, help in the clinic but do not replace examination.
- Nerve conduction studies and electromyography confirm and locate peripheral nerve damage.
- Imaging only when it answers a question raised by the exam (for example, radiculopathy with deficit).
Test yourself
Think of the answer, then tap the question to see it.
Why is diaphragmatic irritation felt at the shoulder tip?
The diaphragm is supplied by the phrenic nerve (C3 to C5), the same segments that supply the skin over the shoulder, so the pain is referred there.
What is allodynia?
Pain caused by a stimulus that is not normally painful, such as light touch from clothing; it is typical of neuropathic pain.
How does visceral pain differ from somatic pain?
Visceral pain is deep, poorly localized, often midline and cramping with nausea and sweating; somatic pain is well localized and worse with movement or pressure.
Which type of pain is fibromyalgia an example of?
Nociplastic pain, from altered central pain processing without clear tissue or nerve damage.
Connections
See it in 3D2
The structures of Durgical's 3D anatomy where it is found.
Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.
Sources: Overview of Pain (MSD Manual Professional Edition, 2025); Neuropathic Pain (MSD Manual Professional Edition, 2025).
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Representative model, for educational purposes only.