Pain Manifestations of COVID-19 and Their Association With Mortality: A Multicenter Prospective Observational Study

Mayo Clin Proc. 2021 Apr;96(4):943-951. doi: 10.1016/j.mayocp.2020.12.014. Epub 2020 Dec 26.


Objectives: To determine the prevalence and breakdown of pain symptoms among patients with coronavirus disease 2019 (COVID-19) infection admitted for nonpain symptoms and the association between the presence of pain and intensive care unit (ICU) admission and death.

Patients and methods: In this multicenter prospective study, data on the intensity and type of pain were collected on 169 patients with active severe acute respiratory syndrome coronavirus 2 infection at 2 teaching hospitals in the United States and Korea and on 8 patients with acute pain at another large teaching hospital between February 1, 2020, and June 15, 2020.

Results: Sixty-five of 169 patients (38.5%) reported an active pain condition. Among the 73 patients with pain, the most common pain symptoms were headache (n=22; 30.1%), chest pain (n=17; 23.3%), spinal pain (n=18; 24.7%), myalgia (n=13; 17.8%), abdominal or pelvic pain (n=13; 17.8%), arthralgia (n=11; 15.1%), and generalized pain (n=9; 12.3%). Those reporting headache as their main symptom were less likely to require ICU admission (P=.003). Acetaminophen or nonsteroidal anti-inflammatory drugs were prescribed to 80.8% (n=59), opioids to 17.8% (n=13), adjuvants to 8.2% (n=6), and ketamine to 5.5% (n=4) of patients with pain. When age 65 years and older and sex were controlled for in multivariable analysis, the absence of pain was associated with ICU admission (odds ratio, 2.92; 95% CI, 1.42 to 6.28; P=.004) and death (odds ratio, 3.49; 95% CI, 1.40 to 9.76; P=.01).

Conclusion: Acute pain is common during active COVID-19 infection with the most common manifestations being headache, chest pain and spine pain. Individuals without pain were more likely to require intensive care and expire than those with pain. Reasons why pain may be associated with reduced mortality include that an intense systemic stimulus (eg, respiratory distress) might distract pain perception or that the catecholamine surge associated with severe respiratory distress might attenuate nociceptive signaling.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Acute Pain* / diagnosis
  • Acute Pain* / etiology
  • Acute Pain* / physiopathology
  • Age Factors
  • COVID-19* / epidemiology
  • COVID-19* / physiopathology
  • COVID-19* / therapy
  • Female
  • Hospitalization / statistics & numerical data
  • Humans
  • Intensive Care Units / statistics & numerical data
  • Male
  • Middle Aged
  • Outcome and Process Assessment, Health Care
  • Pain Management / methods*
  • Pain Measurement / methods*
  • Pain Perception / physiology*
  • Republic of Korea / epidemiology
  • Sex Factors
  • United States / epidemiology