Current Pain and Headache Reports (2019) 23:88

https://doi.org/10.1007/s11916-019-0827-4

HOT TOPICS IN PAIN AND HEADACHE (N ROSEN, SECTION EDITOR)

Pain: Is It All in the Brain or the Heart?

Ali M. Alshami 1

# Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Purpose of Review Scientists have reported that pain is always created by the brain. This may not be entirely true. Pain is not only
a sensory experience, but also can be associated with emotional, cognitive, and social components. The heart is considered the
source of emotions, desire, and wisdom. Therefore, the aim of this article was to review the available evidence about the role of
the heart in pain modulation.
Recent Findings Dr. Armour, in 1991, discovered that the heart has its “little brain” or “intrinsic cardiac nervous system.” This
“heart brain” is composed of approximately 40,000 neurons that are alike neurons in the brain, meaning that the heart has its own
nervous system. In addition, the heart communicates with the brain in many methods: neurologically, biochemically,
biophysically, and energetically. The vagus nerve, which is 80% afferent, carries information from the heart and other internal
organs to the brain. Signals from the “heart brain” redirect to the medulla, hypothalamus, thalamus, and amygdala and the
cerebral cortex. Thus, the heart sends more signals to the brain than vice versa. Research has demonstrated that pain perception is
modulated by neural pathways and methods targeting the heart such as vagus nerve stimulation and heart-rhythm coherence
feedback techniques.
Summary The heart is not just a pump. It has its neural network or “little brain.” The methods targeting the heart modulate pain
regions in the brain. These methods seem to modulate the key changes that occur in the brain regions and are involved in the
cognitive and emotional factors of pain. Thus, the heart is probably a key moderator of pain.

Keywords Brain . Emotion . Heart . Hurt . Pain

Abbreviations considerable evidence regarding the role of the central ner-

CNS central nervous system vous system (CNS), particularly higher levels of the brain, in
HRV heart rate variability processing innocuous information and pain [2]. However, cur-
VNS vagus nerve stimulation rent evidence has shown the role of the heart in the modulation
of acute and chronic pain [3•, 4••]. Most research has focused
on the heart and the responses of the human body to the com-
Introduction mands of the brain. Few scientists have examined the signals
that the heart sends to the brain and response of the brain to
Current pain research involves the slogan “No brain, no pain.” these signals. Therefore, this paper proposes the statement
Professor Lorimer Moseley [1] reported that “Pain is always – “No heart, no hurt,” meaning that the heart is a key moderator
100% of the time – created by your brain in an attempt to of pain. The following discussion is intended to support this
make you do something to protect your body.” There is argument. Therefore, the aim of this article was to review the
available evidence about the role of the heart in pain
This article is part of the Topical Collection on Hot Topics in Pain and modulation.
Headache

* Ali M. Alshami
[email protected] Pain Definition
1
Department of Physical Therapy, College of Applied Medical
Sciences, Imam Abdulrahman Bin Faisal University, P.O. Box 2435, The International Association for the Study of Pain defines
Dammam 31441, Saudi Arabia pain as:
 88 Page 2 of 4 Curr Pain Headache Rep (2019) 23:88

an unpleasant sensory and emotional experience asso- For example, atrial peptide or atrial natriuretic peptide, which
ciated with actual or potential tissue damage, or de- inhibits the release of stress hormones, reduces sympathetic
scribed in terms of such damage. [5] outflow and influences motivation and behavior [8].
Moreover, the main source of the brain natriuretic peptide is
Many people report pain, particularly chronic pain, in the cardiac ventricle rather than the brain. The heart also man-
the absence of any pathophysiological cause or tissue ufactures and secretes oxytocin, the so-called “love” or “social
damage. Pain has several dimensions: sensory, emotional, bonding” hormone, which is involved in cognition, tolerance,
cognitive, and cultural [5]. Several studies demonstrated trust, etc. [8].
that chronic pain patients display key changes in several The vagus nerve is the tenth cranial nerve, which carries
brain regions, particularly the regions involved in cogni- information from the heart and other internal organs to the
tive and emotional factors of pain. These changes include brain. It terminates in the brainstem, particularly in the medul-
the pain neuromatrix, structural and functional changes in la, and solitary nucleus [8]. The vast majority (80%) of the
the brain, and alteration of descending antinociceptive vagus nerve fibers are afferent (ascending). This means, as
pathways [2]. Cognitive and emotional factors critically previously mentioned, that the heart sends more signals to
influence pain perception [5]. The heart plays a major role the brain than vice versa [4••]. Interestingly, signals from the
in creating emotions. It was recently shown that the car- “heart brain” transmit to the head brain via afferent neurons in
diovascular system and the heart send more signals to the the spine as well as the vagus nerve, where the signals redirect
brain than the brain sends to the heart (see below) [4••]. to the medulla, hypothalamus, thalamus, amygdala, and then
to the cerebral cortex [4••]. There is evidence that a pathway
from the dorsal vagal complex and cardiovascular afferent
“Heart Brain” signals travels directly to the frontal cortex [8].

In many cultures, such as Hebrew, Christian, Chinese, Emotions and the Heart
Hindu and Islamic, the heart is considered the source of
emotions, desire, and wisdom [6]. Dr. J. Andrew Armour, As previously explained, pain experience is not only sen-
in 1991, first introduced the concept of “heart brain,” sory but also emotional, cognitive, and cultural.
“little brain,” or “intrinsic cardiac nervous system.” This Alterations in the forms of afferent input to the brain
“heart brain” is composed of approximately 40,000 neu- result in significant changes in emotion, cognition, per-
rons that are able to sense, feel, learn, and even remember. ception, behavior, and physiological function. The heart
These neurons in the heart are alike the neurons in the sends afferent input that influences the homeostatic con-
brain [6]. Cardiac afferent neurons are located in both trol areas in the brain. Interestingly, this input from the
the dorsal root and nodose ganglia as well as in the in- heart also affects the activity of higher brain areas com-
trinsic cardiac and intrathoracic ganglia. The intrinsic car- prised in the processing of emotion, cognition, and per-
diac neurons can generate spontaneous activity indepen- ception [8]. Recently, research at the Institute of
dent of inputs from central and other intrathoracic neurons HeartMath has shown that stress and emotions are highly
[7]. Thus, the heart has its own nervous system. In this reflected by heart rate variability (HRV), which is a prod-
perspective, the heart is a system that is complex and self- uct of the dynamic interaction of several systems of the
organized. It maintains a constant two-way communica- body. Beat-to-beat variability in both heart rate and blood
tion with the brain and the whole body [7]. pressure is mainly produced and augmented by the inter-
action between the heart and brain. This is demonstrated
by increased vagal afferent information sent from the car-
Heart-Brain Communication diovascular system and heart to the brain. In addition, this
interaction is mediated by afferent and efferent neural
Literature has demonstrated that the heart communicates with pathways of the autonomic nervous system through its
the brain in many methods: through nerve impulses (neuro- sympathetic and parasympathetic branches. Emotion and
logically), via hormones (biochemically), through pulse physiological synchronization is directly related to heart
waves (biophysically), and through electromagnetic fields rhythm, rather than the rate. Positive emotions like appre-
(energetically) [4••]. In comparison to the brain, the heart pro- ciation result in more coherent heart rhythms—a stable
duces 40–60 times more electrical power and 5000 times more form of repeating sine waves. On the other hand, heart
electromagnetic power. Consequently, the heart can align and rhythms associated with negative emotions such as anxi-
synchronize all body systems to create physiological coher- ety, worry, and frustration are more incoherent—highly
ence [6]. The heart produces and secretes several hormones. variable and erratic. This indicates less synchronization
Curr Pain Headache Rep (2019) 23:88 Page 3 of 4 88

in the alternate action of the parasympathetic and sympa- activation of the vagus nerve, which consequently modulates
thetic nervous systems [4••, 8]. any of the aforementioned five mechanisms and potentially
increases the excitability of the CNS. It has been demonstrated
that left VNS inhibits approximately 60% of the spinothalamic
Pain and the Heart cells [8].

Research on humans and animals has demonstrated that pain

perception is modulated by neural pathways and methods
targeting the heart. Recently, Frangos et al. [3•] reviewed 23 Conclusion and Future Recommendation
studies that investigated invasive and non-invasive vagus
nerve stimulation (VNS). The authors concluded that VNS The recent scientific evidence revealed that the heart is
has positive effects on mechanical and/or thermal pain percep- not just a pump, has its neural network or “heart brain,”
tion and psychological factors associated with pain experience and is the most powerful system that generates signals in
in patients with various conditions such as low back pain, the human body. In addition, the methods targeting the
chronic pelvic pain, fibromyalgia, and headache [3•]. The heart modulate the perception of pain. These methods
aforementioned findings are consistent with other studies that seem to modulate the key changes that occur in the brain
used heart-rhythm coherence/HRV feedback techniques. regions and are involved in the cognitive and emotional
Heart-rhythm coherence feedback aims at facilitating skill ac- factors of pain. Therefore, the proposition of the current
quisition of self-regulation to develop a greater awareness of article “No heart, no hurt” may be plausible to emphasize
the connection between emotions, physiology, and behavior that the heart is a key moderator of pain, irrespective of
[4••]. The HeartMath Institute uses these techniques to reduce the role of the brain in the modulation of pain. Although
patients’ pain, often to the extent that they can minimize the there appears to be growing foundation to consider this
use of pain medications. Similar to VNS, these techniques proposition, further clinical trials with robust methodolo-
have proven effective in patients with numerous conditions, gies are needed.
including visceral, cutaneous, and chronic musculoskeletal
pain; fibromyalgia; serious burns; and traumatic brain injury Compliance with Ethical Standards
[4••, 8].
Several mechanisms may be referred to the vagal modula- Conflict of Interest The authors declare no conflicts of interest relevant
to this manuscript.
tion of pain. In a review, De Couck et al. [9] attributed the
influence of vagal modulation of pain to five mechanisms:
Human and Animal Rights and Informed Consent This article does not
inflammation, sympathetic nervous system, oxidative stress, contain any studies with human or animal subjects performed by any of
brain activity, and opioids. The vagus nerve in general can the authors.
inhibit inflammation, especially in a pain condition. Afferent
input from VNS can modulate sympathetic input and stress
via modulating descending noradrenergic and serotonergic
neurons and, consequently, reduce pain. Vagal nerve activity References
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