Long COVID affects a significant portion of people who have had COVID-19, with symptoms lasting for months or even years after the initial infection1. Among the many symptoms reported, pain emerges as the most common and debilitating complaint, affecting over a quarter of individuals with long COVID2. This persistent pain can take many forms and impacts quality of life substantially, highlighting the need for better understanding and management strategies3.
Long COVID Overview
Long COVID, also known as post-COVID-19 condition or post-acute sequelae of SARS-CoV-2 (PASC), is a complex, multisystem illness characterized by symptoms persisting beyond three months after acute COVID-19 infection45. There is currently no universally agreed-upon definition, but the World Health Organization describes it as symptoms continuing or developing three months after initial infection and lasting for at least two months5. Diagnosis relies on clinical evaluation and symptom history, as no specific biomarker or laboratory test exists to confirm long COVID5.
Long COVID encompasses a wide range of symptoms affecting multiple organ systems, including fatigue, respiratory difficulties, cognitive impairment (often called brain fog), sensory impairments, psychological symptoms, and musculoskeletal pain61. The condition can occur even in individuals who had mild or asymptomatic acute COVID-19 and may fluctuate over time1. Risk factors for developing long COVID include female sex, older age, and severity of the initial illness, as well as socioeconomic deprivation789.
- Long COVID is a chronic condition triggered by SARS-CoV-2 infection, with symptoms lasting beyond three months45.
- Symptoms include fatigue, cognitive problems, respiratory issues, sensory impairments, and pain61.
- Diagnosis is clinical, based on symptom history, due to lack of definitive tests5.
- Risk factors include female gender, older age, initial illness severity, and socioeconomic factors789.
- Symptoms may persist, worsen, or fluctuate over time1.
Common Long COVID Symptoms
Research involving over 1,000 adults with long COVID found that pain was the most frequently reported symptom, accounting for more than 26% of all symptoms recorded210. Nearly half of patients reported experiencing some form of pain during their illness2. Pain types varied widely, including headaches, muscle aches (myalgia), joint pain, neuropathic pain (such as burning or tingling sensations), and chest or abdominal pain11122. Pain was reported in multiple body sites, including the head, chest, limbs, eyes, ears, back, and jaw11210.
Other common symptoms included neuropsychological issues (18%), fatigue (14%), and shortness of breath (7%)2. Symptom intensity was influenced by demographic factors: older adults experienced more severe symptoms, with those aged 68 to 87 reporting up to 86% higher symptom intensity compared to younger adults92. Women were more likely to report intense pain than men, and people of color experienced more severe symptoms than white individuals92. Higher education levels and living in less deprived areas were associated with lower symptom severity92.
- Pain is the most common symptom, reported by over 26% of long COVID patients210.
- Types of pain include headache, myalgia, joint pain, neuropathic pain, and chest or abdominal pain11122.
- Pain affects multiple body sites: head, chest, limbs, eyes, ears, back, and jaw112.
- Other frequent symptoms: neuropsychological issues, fatigue, and shortness of breath2.
- Older age, female sex, ethnicity, education, and socioeconomic status influence symptom severity92.
💡 Did You Know?
Long COVID symptoms can include over 200 reported manifestations, with pain being a major contributor to disease burden and reduced quality of life13.
Why Pain Is the Top Symptom
Although COVID-19 primarily affects the respiratory system, long COVID pain is widespread and often persistent, suggesting complex underlying mechanisms13. Researchers propose several explanations for why pain is the most reported symptom in long COVID.
Pain in long COVID is often multifaceted, involving immune, neurological, and vascular factors. A multidisciplinary approach tailored to individual symptoms offers the best chance for relief131419.
One leading theory involves immune-mediated inflammation triggered by the virus, which disrupts neurovascular function—the interaction between nerves and the smallest blood vessels1413. This disruption can impair oxygen and energy delivery to muscles and nerves, resulting in pain13. Additionally, long COVID may damage small nerve fibers, causing small-fiber neuropathy, which manifests as burning, shooting, or tingling pain sensations1415.
Another contributing factor is autonomic nervous system dysfunction (dysautonomia), which can amplify pain signaling and alter pain responses16. This mechanism overlaps with chronic pain syndromes seen in other post-viral conditions, such as fibromyalgia and chronic fatigue syndrome17. Furthermore, chronic overlapping pain conditions (COPCs) increase the risk of developing long COVID features, including pain, regardless of acute COVID status1817.
- Immune-mediated inflammation disrupts neurovascular function, causing pain1413.
- Small-fiber neuropathy damages tiny nerve endings, leading to neuropathic pain1415.
- Autonomic nervous system dysfunction amplifies pain signaling16.
- Pain in long COVID shares mechanisms with other chronic pain syndromes17.
- Pre-existing chronic pain conditions increase risk and severity of long COVID pain1817.
Treating Long COVID Pain
Managing pain related to long COVID is challenging due to its complex, multisystem nature and the variety of pain types involved14. Current treatment approaches are symptomatic and supportive, emphasizing individualized, multidisciplinary care19.
“Long COVID really seems to affect the autonomic nervous system, which includes pain and pain responses.”
— Medical director, Post-COVID-19 Program at UT Health Austin2
Initial management strategies include lifestyle modifications to minimize pain, physical rehabilitation, and psychological therapies such as cognitive behavioral therapy to address stress and coping2014. Pharmacological treatments commonly used include nonsteroidal anti-inflammatory drugs (NSAIDs) and medications targeting neuropathic pain, such as gabapentin and pregabalin201415.
For patients who do not respond to these treatments, experimental therapies like hyperbaric oxygen or immunomodulatory drugs used in autoimmune disorders may be considered, although evidence remains limited20. Optimizing the environment for nerve healing, including controlling comorbidities like diabetes and supplementing vitamins B1 and B12 when deficient, may support recovery in cases of peripheral neuropathy15.
- Lifestyle adjustments and pacing daily activities to reduce pain flare-ups2014.
- Physical therapy and rehabilitation to improve function and reduce pain2014.
- Psychological support, including cognitive behavioral therapy, to manage stress2014.
- Pharmacologic options: NSAIDs, gabapentin, pregabalin, duloxetine for neuropathic pain201415.
- Experimental treatments such as hyperbaric oxygen and immunomodulators under investigation20.
