No, Seriously—Pain Is Real!

Yesterday I saw two commercials back-to-back that reflect chronic pain patients' perceived credibility gap.

1. Migraine
The first ad is a short spot for Excedrin Migraine, starring Elisabeth Moss:

If you have migraines, you know pain. These things are for real. So is Excedrin Migraine. It starts relieving migraine pain in half an hour. That's not all--it gets rid of sensitivity to light and sound. Everything.

Now, I do have migraines, although they are pretty well under control these days (unless a storm rolls in suddenly). My migraines sneer at Imitrex, let alone Excedrin Migraine, which is just plain old Excedrin Extra Strength with a different label. The ingredients are exactly the same: 250 mg acetaminophen, 250 mg aspirin and 65 mg caffeine*.

Fortunately for me (but not for him), the neurologist who diagnosed my migraines has migraines himself. And rheumatoid arthritis. He needs no convincing that pain is "real". But it is a common myth that migraine is not "real" and that people with migraines just "can't handle life", as the non-profit migraine awareness group MAGNUM puts it. If you have migraines, you had better hope your doctor takes your pain seriously: according to the journal Neurology's Multispecialty consensus on diagnosis and treatment of headache , only about half of migraine sufferers receive a medical diagnosis and only 28% are very satisfied with treatment.

Even when a doctor is thoroughly considering her patient's pain, the pervasive cultural idea that chronic pain is not "real" can combine with poor communication to leave the patient feeling dismissed. Dr. Dawn A. Marcus of the University of Pittsburgh's Multidisciplinary Headache Clinic says it well in her article Talking to Your Headache Doctor:

Often, what doctors say is very different from what patients hear. For example, a doctor trying to reassure a patient that her headaches aren’t caused by a serious problem might say, “You don’t have any serious medical problems.” In response, the patient might think, “Oh no! Everybody thinks I’m faking my headaches. I can’t even find a doctor who takes me seriously.”

So even if your doctor is acting in good faith, poorly-worded attempts to reassure you that your life is not in immediate danger** can read as "it's just in your head". Doctors and patients alike need to be more aware of the way that cultural narratives follow us into the exam room.

2. Fibromyalgia
The second commercial promotes Lyrica for the treatment of fibromyalgia. I cannot find a video or transcript anywhere, but the advert shows a woman carrying a big platter of food to a crowd of waiting guests. She says she has fibromyalgia and adds, "the pain is real, but I'm not the kind of person to lie down and quit". Later in the ad, the woman cheerfully informs us, "and, Lyrica is not an anti-depressant!".

This Lyrica commercial is a disaster on several fronts. We not only see the woman having to assert that her pain is "real", but also that she isn't one to lie down and quit, as though other fibromyalgia patients are. Furthermore, the advert shows Lyrica giving the patient enough energy to host a whole yardful of hungry guests, with the implication that if you do not, then you're a quitter. Finally, there is an oblique stigmatizing of mental illness when the woman asserts that Lyrica is "not an anti-depressant!". She doesn't clarify what the implied advantage really is—fewer side effects, perhaps. This vagueness, combined with the "I'm no quitter" framing, makes the assertion read as "you won't have to take those drugs—you know, the ones for mopey old quitters."

I do not have fibromyalgia and have no personal experience with it. But the cultural stigma attached to fibromyalgia is obvious even to an outsider like me when such mainstream sources as The New York Times and The Journal of Rheumatology are still wringing their hands over the "reality" of fibromyalgia nearly twenty years after the American College of Rheumatology established diagnostic criteria.

The Excedrin and Lyrica commercials reflect the cultural stereotype that chronic pain is not "real" by asserting that it is, but in so doing they also reinforce that stereotype. The commercials could have simply said that their products address the severe recurrent pain of migraine or the chronic widespread pain of fibromyalgia. Those phrases recognize the reality of the pain. By insisting that the pain is "real", the adverts invoke the idea that people with chronic pain are fakers.

N.B.: these two commercials are American, but the United States is hardly the only culture that has a problem acknowledging chronic pain as real.

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* Everyone is different, so I'm not saying Excedrin Migraine won't work for anyone—perhaps those whose headaches respond well to caffeine would like it. But slapping "Migraine" on the label and implying that it's specially formulated is disingenuous.

** In the case of migraines, bear in mind that the risk of stroke goes up. Your doctor should discuss stroke risk with you, so be sure to ask.