Long COVID pain can involve several biological mechanisms, including altered pain processing, inflammation, immune dysfunction, small-fibre neuropathy and autonomic dysfunction. Central sensitisation may contribute to widespread pain and sensory hypersensitivity in some people, but it does not explain every type of Long COVID pain. Treatment depends on the symptoms, their possible causes and whether post-exertional malaise (PEM) is present.
Last reviewed: October 2026 | Brain fog friendly
Key Facts
- Long COVID pain can include muscle aches, joint pain, headaches, nerve pain, chest discomfort and pain from normally harmless touch.
- Central sensitisation may amplify pain signals, but it is not the only possible mechanism.
- Small-fibre neuropathy has been objectively identified in some people with painful Long COVID.
- Fibromyalgia and Long COVID can overlap, although they are not necessarily the same condition.
- Pain that worsens after exertion may be part of PEM and requires a different approach from ordinary muscle soreness.
- There is no single proven treatment for all Long COVID pain.
You wake up feeling as though you have spent the night moving furniture. Except you haven’t moved anything. Yesterday’s biggest physical achievement may have been taking a shower, and somehow your muscles are behaving as though you have completed a marathon.
Or perhaps your pain is different. Your feet burn. Your skin hurts when clothing touches it. Your head aches after twenty minutes of concentration. A perfectly ordinary sound feels physically unbearable.
And then the tests come back normal.
This is one of the more frustrating aspects of Long COVID pain: it can be substantial, persistent and life-changing without producing an obvious abnormality on routine investigations.
But pain is not imaginary simply because a standard test has not identified its cause.
Research increasingly suggests that several biological processes may contribute to pain after COVID, including changes in peripheral nerves, inflammatory and immune pathways, autonomic regulation and the way the central nervous system processes pain.
Understanding which processes might be involved matters because not all Long COVID pain is the same, and not all pain responds to the same treatment.
The Different Types of Long COVID Pain
Long COVID pain is not one symptom. It can take several forms, sometimes occurring together.
Widespread muscle and joint pain can feel like the body aches of influenza, except the flu never quite finishes. Some people experience persistent aching, while others notice pain that increases after physical or cognitive exertion.
Headaches may be persistent or recurrent, sometimes resembling migraine or tension-type headache. Light, noise, screens, concentration and changes in posture can make them more difficult to tolerate.
Nerve pain may feel like burning, electric shocks, pins and needles or painful temperature changes. Some people also experience numbness or altered skin sensation. These symptoms can suggest peripheral nerve involvement, although they do not establish a diagnosis on their own.
Chest pain and tightness can have several causes, including musculoskeletal problems and inflammation of the chest wall. Cardiac, respiratory and vascular causes must also be considered, particularly when symptoms are new or changing.
Allodynia is pain caused by something that would not normally be painful. Clothing, light touch or a mild temperature change may become difficult to tolerate.
Sensory hypersensitivity can make light, sound and busy environments feel physically uncomfortable or exhausting. It may overlap with pain-processing changes, migraine, autonomic symptoms and other neurological processes.
The common thread is not necessarily one mechanism. It is that COVID may leave several systems involved in pain and sensory regulation functioning differently.
Central Sensitisation: When the Volume Dial Is Turned Up
One of the most useful concepts in chronic pain research is central sensitisation.
Imagine the nervous system has a volume dial.
Under ordinary circumstances, pain-processing pathways respond to incoming signals and adjust their sensitivity. When something is injured or inflamed, those pathways may become more responsive to help protect the body.
Central sensitisation describes a state in which parts of the brain and spinal cord become more responsive to sensory input. Signals that previously caused little discomfort may become painful, and existing pain may feel more intense.
The volume dial has been turned up.
The important point is that this is a physiological concept about nervous-system processing. It does not mean someone is exaggerating pain, imagining symptoms or experiencing pain because of anxiety.
Researchers have proposed central sensitisation as one possible contributor to widespread pain and sensory hypersensitivity in Long COVID.
A 2025 review in Expert Review of Neurotherapeutics explored central sensitisation as a framework connecting features of Long COVID, fibromyalgia and ME/CFS. It presented a particular interpretation of these overlapping conditions rather than establishing that all Long COVID symptoms share one cause.
That distinction is important.
Central sensitisation may help explain why pain becomes widespread, why ordinary touch can hurt and why sensory stimulation becomes overwhelming.
But it cannot automatically explain every case of chest pain, neuropathy, inflammatory joint pain or post-exertional worsening.
And it should never be used as a reason to stop investigating other possible causes.
What Might Contribute to Pain Sensitisation?
Several processes may interact.
Neuroimmune and inflammatory signalling may influence how pain pathways respond to sensory input. Researchers are investigating these mechanisms in Long COVID, although the precise relationships remain uncertain.
Peripheral nerve dysfunction can produce abnormal sensory signals that may contribute to persistent pain. Small-fibre neuropathy is particularly relevant because it has been objectively identified in selected Long COVID cohorts.
Autonomic dysfunction may coexist with pain, altered temperature regulation, headaches and other symptoms. The autonomic and pain-processing systems interact, but the presence of dysautonomia does not establish that it is causing someone’s pain.
Poor sleep can increase pain sensitivity. Persistent pain can also disturb sleep, creating a difficult two-way relationship.
The result may be several overlapping mechanisms rather than one faulty switch.
The Fibromyalgia Overlap — and Why It Matters
Fibromyalgia and Long COVID share some striking features.
Both can involve widespread pain, fatigue, sleep disturbance, cognitive difficulties and sensory sensitivity. Some people who develop persistent symptoms after COVID also meet diagnostic criteria for fibromyalgia.
That overlap is clinically important.
It means that research and treatment approaches developed for fibromyalgia may help clinicians understand and manage certain Long COVID pain patterns.
But fibromyalgia and Long COVID are not automatically the same condition.
Fibromyalgia is a recognised chronic pain condition involving altered pain processing and potentially other biological mechanisms. Long COVID is a broader post-infectious condition that can affect multiple organ systems and produce a wide range of clinical presentations.
A person can have both diagnoses. Their symptoms may overlap substantially. In some cases, the onset of widespread pain after COVID may lead to a fibromyalgia diagnosis.
None of this proves that the two conditions are biologically identical.
The 2025 central-sensitisation review proposed that some Long COVID presentations resemble central sensitivity syndromes. Other research has identified peripheral nerve abnormalities, immune changes, vascular abnormalities and other findings that complicate any attempt to explain the entire condition through one framework.
If you have received a fibromyalgia diagnosis after COVID, it is reasonable to discuss whether the conditions are related and whether treatments used for fibromyalgia could help your particular symptoms.
It is not necessary to decide that one diagnosis cancels out the other.
What About ME/CFS?
Long COVID and ME/CFS can also overlap, particularly where post-exertional malaise, unrefreshing sleep, cognitive difficulties and orthostatic intolerance are present.
However, PEM is not simply central sensitisation or increased pain sensitivity.
PEM involves worsening of symptoms after exertion, often with a delayed onset and prolonged recovery. Its underlying biology remains under investigation.
This distinction matters when considering rehabilitation or activity recommendations.
Pain Is More Than Just Pain
Pain rarely arrives alone.
For some people, a pain flare occurs alongside worse fatigue, brain fog, dizziness, sensory sensitivity or PEM.
That does not prove all these symptoms arise from the same mechanism. It does suggest that they may interact.
Poor sleep can make pain harder to tolerate. Pain can make sleep worse. Orthostatic symptoms can make sitting or standing more demanding. Cognitive exertion may contribute to an overall symptom flare in someone who experiences PEM.
Sometimes the most useful question is not simply “How do I stop this pain?”
It is “What else happens when the pain gets worse?”
The answer may help identify patterns that are useful for clinical assessment and symptom management.
Headaches in Long COVID
Headaches are commonly reported after COVID, but they do not all have the same cause.
Some resemble migraine. Others resemble tension-type headaches, new daily persistent headache or headaches associated with other medical conditions.
For people with Long COVID, headaches may coexist with light sensitivity, sound sensitivity, cognitive fatigue or orthostatic symptoms.
A headache that becomes worse while upright and improves after lying down may be particularly worth discussing with a clinician, because posture-related headaches can have causes that require specific assessment.
The presence of brain fog does not automatically mean that reduced cerebral blood flow is causing a headache. Nor does a pressure sensation necessarily mean there is abnormal pressure inside the skull.
Treatment should be guided by the headache pattern and any concerning associated symptoms.
Migraine-specific treatments, preventive medication and other established headache approaches may be appropriate depending on the diagnosis.
Frequent use of pain-relief medication can itself contribute to medication-overuse headache, so persistent headaches deserve an individual treatment plan rather than increasingly frequent doses of the same analgesic.
Nerve Pain and Small-Fibre Neuropathy
Burning feet. Electric shocks. Tingling hands. Skin that feels painfully hot or cold.
These symptoms can be particularly unsettling because they may occur without visible injury.
One possible explanation is small-fibre neuropathy, or SFN.
Small nerve fibres help transmit pain and temperature sensations. Some also participate in autonomic functions, including sweating and blood-vessel regulation.
Research has identified small-fibre abnormalities in selected groups of people with Long COVID.
A 2024 study published in Pain investigated 26 people with painful post-COVID symptoms and found abnormalities compatible with small-fibre neuropathy in 12 participants.
Other studies have identified biopsy-confirmed SFN in patients evaluated after COVID.
These findings matter because they demonstrate that objective peripheral nerve abnormalities can be present in some people with painful Long COVID.
However, these were selected clinical groups. Their results cannot be used to estimate how many people with Long COVID overall have SFN.
How Is Small-Fibre Neuropathy Investigated?
Assessment may include a neurological examination, tests for other causes of neuropathy and specialist investigations such as skin biopsy or quantitative sensory testing.
Standard nerve-conduction studies mainly assess larger nerve fibres and can be normal in people with SFN.
A skin biopsy may identify reduced small-nerve-fibre density, but the decision to investigate depends on the clinical picture.
Small-fibre neuropathy also has causes unrelated to COVID, including diabetes, vitamin deficiencies, autoimmune conditions and other disorders.
If you experience persistent burning pain, electric-shock sensations or altered skin sensitivity, it may be worth asking your GP whether a neurological assessment is appropriate.
What Actually Helps Long COVID Pain?
There is no single treatment that reliably resolves all Long COVID pain.
That may be frustrating, but it reflects the fact that different types of pain can arise through different mechanisms.
NICE recommends individualised assessment and management of persistent post-COVID symptoms, including investigating symptoms that may have other causes and using established approaches for symptom relief where appropriate.
Sleep
Poor sleep can increase pain sensitivity, while persistent pain can make restorative sleep difficult.
Addressing insomnia, sleep apnoea or other sleep problems may improve overall symptom management.
Sleep is important, but it should not be presented as the single most effective treatment for every type of Long COVID pain.
Pacing
If pain worsens alongside fatigue, cognitive difficulties or other symptoms after exertion, post-exertional malaise may be part of the picture.
Pacing aims to manage activity within a person’s current capacity and reduce repeated episodes of symptom exacerbation.
This is different from simply increasing exercise or pushing through pain.
Not every person with Long COVID has PEM, but identifying it is particularly important before recommending physical rehabilitation.
Medication
Different pain patterns may respond to different treatments.
For neuropathic pain, clinicians may consider medications commonly used for nerve pain, depending on the diagnosis and the patient’s medical circumstances.
Amitriptyline and duloxetine are among medications used for certain chronic or neuropathic pain conditions. Their suitability depends on symptoms, other conditions, current medication and possible side effects.
Low-dose naltrexone (LDN) is also being investigated in Long COVID and related conditions. Early findings and clinical interest are encouraging, but it remains an off-label approach without sufficiently strong evidence to establish it as a standard Long COVID pain treatment.
There is no medication proven to reverse central sensitisation specifically in Long COVID.
A GP, neurologist or pain specialist can help assess which established symptom-management options may be appropriate.
Movement Within Individual Tolerance
For someone without PEM, carefully adapted movement may sometimes help with stiffness, mobility and general wellbeing.
For someone with PEM, the priority is different: avoid activities that repeatedly trigger deterioration.
Fixed increases in exercise should not be assumed to be safe or helpful for everyone with Long COVID.
The appropriate amount of movement may vary considerably, including between people who have similar pain symptoms.
Heat, Cold and Practical Comfort
Heat packs, cooling products, comfortable clothing, changes in posture and other simple measures may provide symptom relief.
Temperature sensitivity varies, and some people with dysautonomia tolerate heat or cold poorly.
These measures are not treatments for the underlying cause of Long COVID, but relief does not have to be revolutionary to be worthwhile.
Sometimes the achievement is simply finding a position in which your body stops complaining for twenty minutes.
When Pain Needs Further Investigation
It is important not to attribute every new pain symptom to Long COVID.
New or worsening chest pain, particularly with breathlessness, fainting or other concerning symptoms, requires urgent medical assessment.
Persistent joint swelling, progressive weakness, new neurological deficits, severe or unusual headaches, or significant changes in pain should also be assessed.
Long COVID can coexist with other medical conditions.
A normal routine test does not mean pain is imaginary. Equally, having Long COVID does not mean every pain symptom should automatically be explained by it.
Final Thoughts
Long COVID pain is real, and research increasingly supports the involvement of several biological processes.
For some people, altered central pain processing may be important. For others, peripheral nerve abnormalities, headaches, inflammatory conditions or other problems may contribute.
Often the picture is more complicated than one mechanism.
The encouraging part is that understanding pain patterns can help identify more appropriate assessments and treatments, even while Long COVID research continues.
The difficult part is that improvement does not follow one timetable.
Some people improve substantially. Others continue to experience persistent pain and require ongoing support.
Neither outcome makes the pain more or less real.
And if your body feels as though it has spent the night moving furniture while you were asleep, you deserve more than being told that your tests look fine.
You deserve someone to investigate what may be happening and help you manage it.
Quick Answers
Why do I have pain all over with no obvious cause?
Because Long Covid pain causes central sensitisation the nervous system’s pain processing system becomes hypersensitised and amplifies signals beyond what the physical input warrants. The pain is real and biological. It is generated by the central nervous system rather than by tissue damage in specific locations, which is why it is widespread and does not localise to one injury or area.
Is fibromyalgia the same as Long Covid pain?
For many patients they are the same biological process central sensitisation triggered by SARS-CoV-2. A June 2025 study confirmed that once Long Covid is considered in patients without clear organ damage, it fits best as a central sensitisation syndrome in the same family as fibromyalgia and ME/CFS. A fibromyalgia diagnosis after Covid infection is almost certainly Long Covid expressing itself through the pain system, not a coincidental separate condition
Why do painkillers not help much?
Because standard painkillers work on peripheral pain signals the signals from damaged or inflamed tissue. Central sensitisation pain is generated in the brain and spinal cord’s processing systems. The problem is in the amplifier, not the input. Medications that target central nervous system sensitisation amitriptyline, duloxetine, low-dose naltrexone are generally more effective than standard analgesics for this type of pain.
What is allodynia and could I have it?
Allodynia is pain from stimuli that should not cause pain light touch, clothing on skin, mild temperature change. It is a hallmark of central sensitisation and is experienced by a significant proportion of Long Covid patients. If gentle touch or ordinary sensations produce pain or marked discomfort, that is allodynia. It is biological and it responds to approaches that reduce central sensitisation rather than to conventional pain management.
Why does my pain get worse after activity?
For the same reason all Long Covid symptoms worsen with exertion post-exertional malaise involves an immune and neurological response to effort that amplifies central sensitisation alongside all other symptoms. The pain flare after activity in Long Covid is not the same as muscle soreness after exercise. It is the sensitised nervous system responding disproportionately to demand.
Will Long Covid pain improve?
For most people, yes gradually over time with appropriate management. Central sensitisation can reduce as neuroinflammation resolves and the conditions that sustain it are addressed. Improving sleep, pacing carefully, and targeting the neuroinflammatory drivers all support this process. The timeline is individual and non-linear, but improvement is documented and realistic for the majority.
Why does light feel painful or overwhelming in Long COVID
n Long COVID, sensitivity to light is not simply an eye problem. It reflects how the brain processes sensory input.
Central sensitisation lowers the threshold at which stimuli are perceived as uncomfortable or painful. Light signals that would normally be filtered and tolerated are amplified as they pass through the nervous system. At the same time, neuroinflammation and altered brain connectivity, particularly in regions involved in sensory processing, can make the visual system more reactive.
This is why people often describe light not just as bright, but as physically uncomfortable or exhausting. It frequently coexists with headaches, brain fog, and fatigue, suggesting a shared underlying mechanism rather than an isolated symptom.
Importantly, this is not psychological sensitivity. It is a measurable change in how sensory information is processed by the brain.
Why do sounds feel too loud or even painful in Long COVID
Sound sensitivity in Long COVID, sometimes described as hyperacusis, reflects the same underlying nervous system dysregulation seen in chronic pain.
The brain normally filters background noise and adjusts the perceived intensity of sounds. In a sensitised state, this filtering is impaired. Ordinary sounds may feel disproportionately loud, intrusive, or even physically uncomfortable.
This can be driven by central sensitisation, autonomic dysregulation, and heightened threat processing in the brain, where neutral stimuli are interpreted as more intense or stressful than they should be. Over time, this can lead to avoidance of noisy environments, increased fatigue after exposure, and worsening of other symptoms such as headaches or cognitive overload.
As with pain, the issue is not the external stimulus itself, but how the nervous system is processing it.
Can Long COVID cause joint pain even if there is no arthritis?
Yes. Many people experience joint pain despite having normal X-rays and no evidence of inflammatory arthritis. In Long COVID, joint pain is often related to altered pain processing, neuroinflammation or surrounding muscle dysfunction rather than permanent joint damage. However, new or persistent joint swelling should always be assessed by a healthcare professional to exclude inflammatory or autoimmune conditions.
Should I keep exercising if movement makes my pain worse?
Not necessarily. If pain consistently worsens 12 to 48 hours after activity, it may be part of post-exertional malaise rather than simple muscle soreness. In this situation, pushing through symptoms can make recovery more difficult. Gentle, symptom-guided movement within your energy limits is usually more appropriate than fixed exercise programmes.
Medical Disclaimer
This article is intended for general educational purposes and does not replace personalised medical advice, diagnosis or treatment.
Long COVID pain can have several possible causes, including conditions unrelated to Long COVID. New, severe, persistent or worsening symptoms should be assessed by an appropriately qualified healthcare professional.
Seek urgent medical assistance for potentially serious symptoms such as new or severe chest pain, sudden neurological changes or an unusually severe headache.
Do not start, stop or change prescribed medication based on this article. Treatment decisions should take account of your medical history, current medications and individual circumstances.
References
- Goldenberg DL. The pivotal role of central sensitization in long COVID, fibromyalgia and myalgic encephalomyelitis/chronic fatigue syndrome. Expert Review of Neurotherapeutics. 2025.
https://pubmed.ncbi.nlm.nih.gov/40512228/ - Falco P, et al. Small fibre neuropathy frequently underlies the painful long-COVID syndrome. Pain. 2024.
https://pubmed.ncbi.nlm.nih.gov/38723183/ - McAlpine LS, et al. Case-Control Study of Individuals With Small Fiber Neuropathy After COVID-19.Neurology: Neuroimmunology & Neuroinflammation. 2024.
https://doi.org/10.1212/NXI.0000000000200244 - Oaklander AL. Increasing associations of long-COVID with small-fiber neuropathy. Pain. 2024.
https://pmc.ncbi.nlm.nih.gov/articles/PMC11343176/ - Marshall A, et al. Small Fibre Pathology in Fibromyalgia: A Review. Pain and Therapy. 2025.
https://pmc.ncbi.nlm.nih.gov/articles/PMC11914468/ - NICE. COVID-19 rapid guideline: managing the long-term effects of COVID-19 (NG188).
https://www.nice.org.uk/guidance/ng188 - NICE. Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management (NG206).
https://www.nice.org.uk/guidance/ng206
Related Reading
When pain gets worse after activity
Post-Exertional Malaise in Long COVID
When pain comes with brain fog and cognitive exhaustion
Long COVID Brain Fog
When dizziness, palpitations or temperature changes occur alongside pain
What Is Dysautonomia in Long COVID?
When fatigue is one of the biggest problems
Long COVID Fatigue
Understanding why Long COVID affects multiple body systems
What Causes Long COVID? What Researchers Know So Far
About This Long COVID Pain Guide
This guide combines lived experience with research into central sensitisation, small-fibre neuropathy, pain processing, fibromyalgia and the wider biological mechanisms being investigated in Long COVID.
It aims to explain what is established, what research suggests and what remains uncertain, while recognising the experience of people living with persistent pain.
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