Chronic Pain and Complementary Health Approaches

What’s the Bottom Line?

How much do we know about the effectiveness of complementary health approaches for chronic pain?

A growing body of evidence suggests that some complementary approaches, such as acupuncture, hypnosis, massage, mindfulness meditation, music-based interventions, spinal manipulation, tai chi, qigong, and yoga, may help to manage some painful conditions.

What do we know about the safety of complementary health approaches for chronic pain?

Although the psychological and/or physical approaches (e.g., acupuncture, meditation, yoga, massage) studied for chronic pain have good safety records, that doesn’t mean that they’re risk-free for everyone. Your health and special circumstances (such as pregnancy) may affect the safety of these approaches. If you’re considering nutritional approaches such as dietary supplements, remember that natural doesn’t always mean safe and that some dietary supplements may have side effects or interact with medications.

What Is Chronic Pain and Why Is It Important?

Chronic pain is pain that lasts more than several months (variously defined as 3 to 6 months, but longer than “normal healing”). It’s a very common problem. Results from the 2019 National Health Interview Survey (NHIS) show that:

About 20.4 percent of U.S adults had chronic pain (defined as pain on most days or every day in the past 3 months).
About 7.4 percent of U.S. adults had high-impact chronic pain (defined as chronic pain that limited their life or work activities on most days or every day for the past 3 months).

More Information

Chronic pain becomes more common as people grow older, at least in part because some health problems that can cause pain, such as osteoarthritis, become more common with advancing age. Military veterans are another group at increased risk for chronic pain; U.S. national survey data show that both pain in general and severe pain are more common among veterans than nonveterans. Chronic pain is more common in rural areas than urban areas in the United States.

Analysis of data from the 2010–2017 NHIS Sample Adult Core and Adult Functioning and Disability Supplement show that prevalence of chronic pain varies by race and Hispanic origin, with a recent publication suggesting the highest percentage among non-Hispanic American Indian/Alaska Native respondents and the lowest among non-Hispanic Asians.

Not all people with chronic pain have a health problem diagnosed by a health care provider, but among those who do, the most frequent conditions are low-back pain or osteoarthritis, according to a national survey. Other common diagnoses include rheumatoid arthritis, migraine, carpal tunnel syndrome, and fibromyalgia.

Chronic pain may result from an underlying disease or health condition, an injury, medical treatment (such as surgery), inflammation, or a problem in the nervous system (in which case it is called “neuropathic pain”); or the cause may be unknown. Pain can affect quality of life and productivity, and it may be accompanied by difficulty in moving around, disturbed sleep, anxiety, depression, and other problems.¹

For more information about chronic pain, visit the National Institute of Neurological Disorders and Stroke website.

¹Certain chronic conditions, several of which cause pain, may occur together; some individuals have two or more of these problems. These conditions include chronic fatigue syndrome, endometriosis, fibromyalgia, interstitial cystitis (painful bladder syndrome), irritable bowel syndrome, temporomandibular joint dysfunction, and vulvodynia (chronic vulvar pain). It is not known whether these disorders share a common cause.

What the Science Says About Complementary Health Approaches for Chronic Pain

The scientific evidence suggests that some complementary health approaches may help people manage chronic pain.

A comprehensive description of scientific research on all the complementary approaches that have been studied for chronic pain is beyond the scope of this fact sheet. This section highlights the research status of some approaches used for common kinds of pain.

Chronic Pain in General

Some recent research has looked at the effects of complementary approaches on chronic pain in general rather than on specific painful conditions.

A 2017 review looked at complementary approaches with the opioid crisis in mind, to see which ones might be helpful for relieving chronic pain and reducing the need for opioid therapy to manage pain. There was evidence that acupuncture, yoga, relaxation techniques, tai chi, massage, and osteopathic or spinal manipulation may have some benefit for chronic pain, but only for acupuncture was there evidence that the technique could reduce a patient’s need for opioids.
Products containing substances from cannabis (marijuana), which typically include both tetrahydrocannabinol (THC) and cannabidiol (CBD), have been tested for their effects on chronic pain in short-term studies. Oral products with high THC/CBD ratios and sublingual (under-the-tongue) products with roughly equal amounts of THC and CBD may reduce chronic pain in the short term but may also have side effects including dizziness and sleepiness. Not much is known about other cannabinoid formulations or the effects of long-term use.
Hypnosis may reduce chronic pain if patients participate in enough sessions (at least eight), according to a few studies.
Studies on chronic pain showed that mindfulness-based interventions and cognitive behavioral therapy are both helpful in decreasing pain intensity and improving physical functioning, with no important difference between the two approaches. Cognitive behavioral therapy is the prevailing psychological intervention for chronic pain.
Studies have shown that music-based interventions can reduce self-reported pain and depression symptoms in people with chronic pain. Effects were greater when the patient, rather than the researcher, chose the music.

Back and Neck Pain

A large review of individual data from multiple studies showed that acupuncture was more effective than either no treatment or sham (fake) acupuncture for back or neck pain. The difference between acupuncture and no treatment was greater than the difference between acupuncture and sham acupuncture. A 2017 clinical practice guideline (guidance for health care providers) from the American College of Physicians (ACP) included acupuncture among the nondrug treatment options for management of both acute and chronic low-back pain.
Evaluations of massage therapy for low-back pain have found weak evidence that it may be helpful. The ACP guideline recommends massage as an option for acute low-back pain, based on low-quality evidence, but does not recommend massage for chronic low-back pain. Massage therapy may be helpful for neck pain, but the benefits may only last for a short time.
Studies show that mindfulness-based stress reduction is associated with a small improvement in chronic low-back pain. The ACP guideline recommends mindfulness-based stress reduction as an option for chronic low-back pain, based on moderate-quality evidence.
Progressive muscle relaxation is one of several nondrug approaches suggested as the first step in treating chronic low-back pain in the ACP treatment guideline. There is evidence that this technique can lead to moderate improvements in low-back pain and back function.
Biofeedback may moderately improve low-back pain. It is one of the nondrug approaches suggested as the first step in treating chronic low-back pain in the ACP treatment guideline.
The 2017 ACP guideline includes spinal manipulation as an option for treating both acute and chronic low-back pain. There is low-to-moderate quality evidence that spinal manipulation can reduce pain and improve function in people with chronic nonspecific neck pain.
Tai chi, either alone or in addition to physical therapy, may decrease the intensity of pain and improve everyday function in people with low-back pain. The ACP guideline includes tai chi as an option for treatment of chronic low-back pain.
Studies of yoga for low-back pain have shown yoga to be helpful in both the short term (1 to just under 6 months) and intermediate term (6 to just under 12 months). The effects of yoga are similar to those of other types of exercise. The 2017 ACP guideline included yoga as an option for initial treatment of chronic but not acute low-back pain. Practicing yoga has been shown to reduce both the intensity of neck pain and disability related to neck pain.
Several types of herbal preparations have been evaluated for low-back pain. There is evidence that topical products containing the herb cayenne, such as creams and plasters, can reduce pain. Topical products that contain two other herbs, comfrey and lavender essential oil, and two herbs used orally, white willow bark and devil’s claw, may also be helpful, but the evidence for these herbs is not as strong as that for cayenne.

For more information, see the National Center for Complementary and Integrative Health (NCCIH) fact sheet on low-back pain.

Osteoarthritis

Acupuncture may be helpful for knee pain associated with osteoarthritis. There’s less evidence on whether it’s helpful for osteoarthritis of the hip. The 2019 clinical practice guideline from the American College of Rheumatology and the Arthritis Foundation conditionally (i.e., weakly) recommends the use of acupuncture for arthritis of the hand, hip, or knee but acknowledges that the evidence on acupuncture is controversial and that most of the studies that have shown beneficial effects have been for knee osteoarthritis.
Low-to-moderate quality evidence suggests that massage may help reduce pain associated with arthritis; most of the research has been on osteoarthritis rather than rheumatoid arthritis. However, the guideline from the American College of Rheumatology and the Arthritis Foundation conditionally (i.e., weakly) recommends against the use of massage therapy for the management of osteoarthritis of the hip or knee because of weaknesses in the scientific evidence.
In research studies, people with osteoarthritis who practiced tai chi experienced improvements in pain, stiffness, balance, and physical function. The guideline from the American College of Rheumatology and the Arthritis Foundation strongly recommends tai chi for the management of osteoarthritis of the knee or hip.
A limited amount of research suggests that yoga may be helpful for improving pain, function, and stiffness in people with osteoarthritis of the knee. The guideline from the American College of Rheumatology and the Arthritis Foundation conditionally recommends yoga for patients with knee osteoarthritis based on similarities to tai chi, which has been studied more extensively.
In their guideline for the management of osteoarthritis of the hand, hip, and knee, the American College of Rheumatology and the Arthritis Foundation strongly recommend against the use of glucosamine for people with arthritis in any of these three body sites. The rationale is that studies with the lowest risk of bias have not shown glucosamine to work better than a placebo (an inactive substance). The guideline also recommends against the use of chondroitin or combination glucosamine/chondroitin products for osteoarthritis of the hip or knee. It conditionally recommends for the use of chondroitin for hand osteoarthritis, however, based on a single study that showed a pain-relieving effect, as well as chondroitin’s apparent safety.
The guideline from the American College of Rheumatology and the Arthritis Foundation conditionally recommends against the use of fish oil for osteoarthritis because only one study exists, and that study did not show efficacy of a higher dose of fish oil over a lower dose. The guideline conditionally recommends against the use of vitamin D for osteoarthritis because the overall evidence does not show a benefit.
There isn’t enough research on dimethyl sulfoxide (DMSO) or methylsulfonylmethane (MSM) for osteoarthritis pain to allow conclusions to be reached. The evidence on S-adenosyl-L-methionine (SAMe) for osteoarthritis of the knee or hip is inconclusive.

For more information, see the NCCIH fact sheet on osteoarthritis.

Rheumatoid Arthritis

The term balneotherapy refers to bathing in mineral water for health purposes and related techniques such as mud packs. There’s evidence that balneotherapy may be helpful for improving quality of life in people with rheumatoid arthritis.
Omega-3 fatty acids of the types found in fish oil may have beneficial effects on rheumatoid arthritis when used in addition to conventional drug therapy.
No nutritional approach other than omega-3 fatty acids has shown clear benefits for rheumatoid arthritis, but there is preliminary evidence for a few dietary supplements, particularly gamma-linolenic acid (contained in evening primrose oil, borage seed oil, and black current seed oil) and the herb thunder god vine.
A few small studies have evaluated tai chi in people with rheumatoid arthritis, but it’s uncertain whether this approach is helpful.

For more information, see the NCCIH fact sheet on rheumatoid arthritis.

Headaches

There’s moderate-quality evidence that acupuncture may reduce the frequency of migraines and moderate-to-low quality evidence that it may reduce the frequency of tension headaches. Studies that compared acupuncture with various drugs for preventing migraine found that acupuncture was slightly more effective and that study participants who received acupuncture were much less likely than those who received drugs to drop out of studies because of side effects.
Studies of electromyography (EMG) biofeedback, a type of biofeedback involving measurements of muscle tension, have found this technique helpful for tension headaches.
Some studies of relaxation techniques for migraines or tension headaches have shown improvements, including a reduction in headache frequency, in people who used the techniques. The evidence is strongest for relaxation techniques used in combination with cognitive behavioral therapy.
Spinal manipulation may reduce the frequency and intensity of cervicogenic headaches (head pain that originates from a problem in the neck). Preliminary evidence suggests it may also be helpful for migraines.
A small amount of research suggests that practicing yoga may reduce headache frequency, headache duration, and pain intensity, with beneficial effects seen primarily in tension headaches rather than migraines.
Several dietary supplements have been studied for migraines. There is some evidence that coenzyme Q10, feverfew, magnesium, and the B vitamin riboflavin might help reduce the frequency of migraines. For all these supplements, the amount of evidence is small. The herb butterbur appears to reduce the frequency of migraines. However, serious concerns have been raised about possible liver toxicity from butterbur.
The results of a recent study showed that diets high in omega-3 fatty acids may be helpful for migraines. Omega-3 supplements have not been shown to make migraines less frequent or severe, but a small amount of evidence suggests that they might reduce the duration of migraine attacks.

For more information, see the NCCIH fact sheet on headaches.

Fibromyalgia

Low-to-moderate quality evidence suggests that acupuncture is helpful for pain associated with fibromyalgia.
Several studies show that massage therapy, if continued for 5 weeks or longer, may reduce pain and improve other symptoms in people with fibromyalgia.
A small amount of research suggests that tai chi can help reduce pain and improve other symptoms in people with fibromyalgia.
The term balneotherapy refers to bathing in mineral water for health purposes and related techniques such as mud packs. There’s evidence that balneotherapy may be helpful for some symptoms of fibromyalgia.
The effectiveness of biofeedback, mindfulness, movement therapies, and relaxation-based therapies for fibromyalgia is unclear because the quality of the evidence on these approaches is low.
Supplementation with vitamin D may reduce fibromyalgia pain, particularly in individuals with vitamin D deficiency.
There is insufficient evidence that other dietary supplements can relieve fibromyalgia pain.

For more information, see the NCCIH fact sheet on fibromyalgia.

Irritable Bowel Syndrome

The evidence suggests that acupuncture is no more effective than sham acupuncture for irritable bowel syndrome (IBS) symptoms, but it may be helpful when used in addition to other forms of treatment.
The 2021 American College of Gastroenterology (ACG) guideline for treatment of IBS suggests that gut-directed hypnotherapy or other gut-directed psychotherapies can be used to treat global IBS symptoms in some patients, but the quality of the evidence is very low.
Probiotics may be helpful for symptoms of IBS, but different strains of probiotics may have different effects. The 2021 ACG guideline suggests that probiotics should not be used for the treatment of IBS symptoms because the current evidence doesn’t clearly show which probiotics might be helpful.
Studies on peppermint have suggested that it may be helpful for overall symptoms and abdominal pain in people with IBS, and the ACG guideline suggests that it can be used, although the evidence is not strong.

For more information, see the NCCIH fact sheet on irritable bowel syndrome.

Less-Studied Complementary Approaches

Research on the plant product kratom is in its early stages, and much more needs to be learned about its effects in the body, its safety, and whether it may have therapeutic uses, including possible use in the treatment of pain.
Reiki is a complementary health approach in which practitioners place their hands lightly on or just above the person, with the goal of facilitating the person’s own healing response. There isn’t enough high-quality research to evaluate whether Reiki is helpful for relieving pain.
Magnets. Both static magnets and electromagnets have been studied as treatments for pain. Static magnets have magnetic fields that don’t change. They may be put into products such as wristbands, shoe insoles, bracelets, and bed pads. There’s not much research on static magnets for pain, and there’s no conclusive evidence that they’re helpful for any type of pain. Electromagnets become magnetic when an electrical current charges the metal. Current research suggests that electromagnetic field therapy can relieve pain and improve function in patients with various musculoskeletal pain conditions and some osteoarthritis conditions, although the data are mixed.

What the Science Says About Safety and Side Effects

As with any treatment, it’s important to consider safety before using complementary health approaches. Safety depends on the specific approach and on the health of the person using it. If you’re considering or using a complementary approach for pain, check with your health care providers to make sure it’s safe for you.

Safety of Psychological and Physical Approaches

Psychological and physical complementary health approaches, such as acupuncture, hypnosis, massage therapy, mindfulness/meditation, music-based interventions, relaxation techniques, spinal manipulation, tai chi, qigong, and yoga, are generally safe for healthy people if they’re performed appropriately.
- People with medical conditions and people who are pregnant may need to modify or avoid some of these practices.
- Like other forms of exercise, complementary health practices that involve movement, such as tai chi and yoga, can cause sore muscles and may involve some risk of injury.
- It’s important for practitioners and teachers of mind and body practices to be properly qualified and to follow appropriate safety precautions.
See the Health Topics A–Z list on the NCCIH website for resources about specific mind and body practices, including information about their safety.

Safety of Nutritional Approaches

“Natural” doesn’t always mean “safe.” Some dietary supplements may have side effects and may interact with medications.
The U.S. Food and Drug Administration has warned the public about several dietary supplements promoted for arthritis or pain that were tainted with prescription drugs.
See the Health Topics A–Z list on the NCCIH website for resources about specific natural products, including information about their safety. For general information on dietary supplements, see NCCIH’s webpage Dietary and Herbal Supplements.

Guidelines for the Treatment of Chronic Pain Conditions

National health professional organizations have issued guidelines for treating several chronic pain conditions that address the use of complementary health approaches.

More Information

A clinical practice guideline from the American College of Physicians encourages the use of nonpharmacologic approaches as initial treatment for chronic low-back pain. The options they suggest include several complementary approaches—acupuncture, mindfulness-based stress reduction, tai chi, yoga, progressive relaxation, biofeedback, and spinal manipulation—as well as conventional methods such as exercise and cognitive behavioral therapy.
The American College of Rheumatology and the Arthritis Foundation have published a guideline for the management of osteoarthritis of the hand, hip, or knee that includes recommendations for or against the use of a variety of complementary health approaches. For example, the guideline strongly recommends for the use of tai chi for osteoarthritis of the hip or knee and strongly recommends against the use of glucosamine for osteoarthritis at any of the three body sites. The guideline’s recommendations are discussed in more detail in the Osteoarthritis section of this fact sheet.
The American College of Gastroenterology clinical guideline for irritable bowel syndrome includes conditional (weak) recommendations in favor of peppermint and gut-directed psychotherapies (a group of therapies that includes gut-directed hypnotherapy). The guideline includes a conditional recommendation against the use of probiotics.
The 2022 Centers for Disease Control and Prevention (CDC) Clinical Practice Guideline for Prescribing Opioids for Pain concludes: “Evidence exists that multiple noninvasive nonpharmacologic interventions improve chronic pain and function, with small to moderate effects in specific pain conditions, and are not associated with serious harms.” Several of the nonpharmacologic approaches discussed in this fact sheet, such as acupuncture, massage therapy, mindfulness-based interventions, tai chi, and yoga, are mentioned in the CDC practice guideline as being appropriate for some types of chronic pain. The guideline recommends maximizing pain treatment with nonpharmacologic and nonopioid pharmacologic treatments as appropriate.

For more information, see NCCIH’s webpage Pain Information for Health Professionals.

NCCIH-Funded Research

NCCIH is part of the National Institutes of Health (NIH) Pain Consortium, which coordinates pain research across NIH. NCCIH-supported studies are helping to build an evidence base on the effectiveness and safety of complementary modalities for treating chronic pain.

NCCIH is also the lead agency in the Pain Management Collaboratory, an initiative jointly supported by NIH, the Department of Defense, and the U.S. Department of Veterans Affairs. The Collaboratory is conducting clinical trials of nondrug approaches for the management of pain and co-occurring conditions in the military and veterans health care systems.

NCCIH is playing a major role in the Helping to End Addiction Long-term Initiative^®, or NIH HEAL Initiative^®, an NIH-wide effort focused on improving prevention and treatment strategies for opioid misuse and addiction and enhancing pain management. NCCIH is leading or co-leading several NIH HEAL Initiative programs that focus on pain management.

NCCIH is leading the Pragmatic and Implementation Studies for the Management of Pain to Reduce Opioid Prescribing (PRISM) program within the NIH HEAL Initiative. PRISM supports pragmatic trial research projects embedded in health care systems. These trials will determine the effectiveness of multiple nonpharmacologic and nonopioid interventions for treating pain and assess the impact of implementing interventions or guidelines to improve pain management and reduce reliance on opioids.

More About NCCIH-Funded Pain Research

NCCIH-supported studies in progress are investigating a variety of topics related to chronic pain, including:

The effect of a combination of chiropractic care and tai chi in people with chronic neck pain
The brain mechanisms by which mindfulness meditation may help to relieve chronic pain
The feasibility of a group-based yoga intervention for women with chronic pelvic pain
The possible effects of light at night and disrupted circadian rhythms on pain

NCCIH’s Division of Intramural Research conducts research focusing on the role of the brain in perceiving, modifying, and managing pain. Research topics include investigating the role of the brain in pain processing and control, and how factors such as emotion, attention, environment, and genetics affect pain perception.

If You're Considering Complementary Health Approaches for Chronic Pain

Don’t use an unproven product or practice to postpone seeing a health care provider about chronic pain or any other health problem.
Learn about the product or practice you are considering, especially the scientific evidence on its safety and whether it works.
Talk with the health care providers you see for chronic pain. Tell them about the product or practice you’re considering and ask any questions you may have. They may be able to advise you on its safety, use, and likely effectiveness.
If you’re considering a practitioner-provided complementary health approach such as spinal manipulation, massage, or acupuncture, ask a trusted source (such as your health care provider or a nearby hospital) to recommend a practitioner. Find out about the training and experience of any practitioner you’re considering. Ask whether the practitioner has experience working with your pain condition.
If you’re considering dietary supplements, keep in mind that they can cause health problems if not used correctly, and some may interact with prescription or nonprescription medications or other dietary supplements. Your health care provider can advise you. If you’re pregnant or nursing a child, or if you’re considering giving a child a dietary supplement, it’s especially important to consult your (or the child’s) health care provider. To learn more, visit NCCIH’s webpage on dietary supplements.

For More Information

NCCIH Clearinghouse

The NCCIH Clearinghouse provides information on NCCIH and complementary and integrative health approaches, including publications and searches of Federal databases of scientific and medical literature. The Clearinghouse does not provide medical advice, treatment recommendations, or referrals to practitioners.

Toll-free in the U.S.: 1-888-644-6226

Telecommunications relay service (TRS): 7-1-1

Website: https://www.nccih.nih.gov

Email: info@nccih.nih.gov (link sends email)

Know the Science

NCCIH and the National Institutes of Health (NIH) provide tools to help you understand the basics and terminology of scientific research so you can make well-informed decisions about your health. Know the Science features a variety of materials, including interactive modules, quizzes, and videos, as well as links to informative content from Federal resources designed to help consumers make sense of health information.

Explaining How Research Works (NIH)

Know the Science: How To Make Sense of a Scientific Journal Article

Understanding Clinical Studies (NIH)

National Institute of Neurological Disorders and Stroke (NINDS)

NINDS conducts and supports research on how the brain and nervous system function and on treatments for neurological diseases.

Toll-free in the U.S.: 1-800-352-9424

Website: https://www.ninds.nih.gov/

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

The mission of NIAMS is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases.

Toll-free in the U.S.: 1-877-22-NIAMS

Website: https://www.niams.nih.gov

PubMed®

A service of the National Library of Medicine, PubMed® contains publication information and (in most cases) brief summaries of articles from scientific and medical journals. For guidance from NCCIH on using PubMed, see How To Find Information About Complementary Health Practices on PubMed.

Complementary Health Approaches for Chronic Pain—Randomized Controlled Trials

Website: https://pubmed.ncbi.nlm.nih.gov/

Cochrane Database of Systematic Reviews

The Cochrane Database of Systematic Reviews is a collection of evidence-based reviews produced by the Cochrane Library, an international nonprofit organization. The reviews summarize the results of clinical trials on health care interventions. Summaries are free; full-text reviews are by subscription only.

Website: https://www.cochranelibrary.com/

Key References

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Coulter ID, Crawford C, Vernon H, et al. Manipulation and mobilization for treating chronic nonspecific neck pain: a systematic review and meta-analysis for an appropriateness panel. Pain Physician. 2019;22(2):E55-E70.
Dowell D, Ragan KR, Jones CM, et al. CDC clinical practice guideline for prescribing opioids for pain—United States, 2022. MMWR. Morbidity and Mortality Weekly Report. 2022;71(3):1-95.
Furlan AD, Giraldo M, Baskwill A, et al. Massage for low-back pain. Cochrane Database of Systematic Reviews. 2015;(9):CD001929. Accessed at cochranelibrary.com on November 8, 2022.
Garza-Villareal EA, Pando V, Vuust P, et al. Music-induced analgesia in chronic pain conditions: a systematic review and meta-analysis. Pain Physician. 2017;20(7):597-610.
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Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis & Rheumatology. 2020;72(2):220-233.
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Other References

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Acknowledgments

NCCIH thanks David Shurtleff, Ph.D., NCCIH, for his review of the 2023 update of this publication.

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Last Updated: January 2023