You twist your ankle, cut your finger, slip and fall, or suddenly experience more severe pain in your back, chest or abdomen that sends you to the emergency room . When you feel that pain, your brain is trying to tell you something. Some kind of tissue injury has occurred. Without proper attention, rest or further treatment, things could get worse. In this case, pain, although uncomfortable, is a helpful warning sign.

But chronic pain is different. In the decades I’ve spent caring for patients who experience chronic pain, especially after the initial injury/condition causing it has apparently healed, I have heard the phenomenon of pain described as a kind of “lonely prison” or “isolating torture chamber.” Often, to loved ones and friends, the outward “appearance” of the individual rarely reflects the severity of the inner havoc the pain is wreaking. These comments are common: “But you look fine.” “You don’t seem like you’re in pain.” “Maybe it’s all in your head…” Over time, individuals often retreat into isolation, interacting less and less with friends and loved ones who “don’t understand” or seemingly “don’t believe” the degree to which they are suffering. Chronic pain becomes a disease unto itself with complications and consequences that can have wide-ranging physical, emotional and functional effects. The brain is still trying to tell you something, but the message is different. Maybe neuroplasticity has resulted in an abnormality for how electrical signals are being processed. Maybe there’s an undiagnosed change in body mechanics, an unresolved emotional issue or poorly managed stress that has heightened sensitivity to pain signals.

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As a neurologist specializing in the care and treatment of people who experience chronic pain, I can tell you that pain — no matter where on the body it’s felt — is very real for the person experiencing it. And yes, it is all in your head, but I mean that quite literally. Pain is not an electrical signal transmitted to the brain from an area of injury or damage. Pain is the emotional experience associated with the signal. And the signal doesn’t become pain until it’s processed and experienced in the brain as unpleasant in some emotional context. The emotional context is critical. That’s why soldiers can rescue others despite personal injury, and football players can “play through” injuries later to find out the nature and severity is such that it’s unbelievable they were able to carry on. Pain is in the brain. And the brain can turn up or turn down the electrical signals to modulate the pain.

Specialized nerves carry electrical pain signals from the site of injury or tissue damage into the spinal cord and eventually to the brain. And the brain sends electrical signals back down to the spinal cord that control or modulate the amount of incoming traffic. We call these pathways ascending and descending pain pathways.

This isn’t as complicated to understand as it may seem. Here’s an example of how ascending and descending pain pathways work: Let’s say you’re involved in a fender-bender and are rear-ended in a minor traffic accident. You exit your car to inspect the damage done by the other car and driver and immediately feel pain in your knee and your neck. Your knee hit the dashboard and your neck suffered a whiplash-like movement. This pain results from signals that access the ascending pathway — starting at the area of injury (your knee and neck), entering the spinal cord, ascending to the brain and then processed (experienced) in the emotional context of the accident as pain. However, let’s say your child or grandchild was in the backseat of the car at the time of the same accident. Your attention would probably immediately focus on the status of the child. And the sensory electrical signals entering the spinal cord from your knee and neck would ascend to the brain but be processed in a different emotional context. Your priorities would be different, as would your focus. The brain would increase the activity of the descending pathway and block the incoming, ascending signals so that you felt no (or less) pain.

[See: 10 Seemingly Innocent Symptoms You Shouldn’t Ignore.]

The above example of this fascinating (at least to us brain docs, though I hope to you, too) pain phenomenon helps illustrate just how involved the brain is in the experience of pain and how different aspects of the ascending and descending pain pathways contribute to the pain experience. The best pain management strategies work by modulating both aspects of the pain pathways and respect the brain’s contribution to pain. Turning down the ascending system and turning up the descending system by using combinations of medications and injections, applying focused cold therapies, electrical, magnetic or radiofrequency stimulation, and training the brain through cognitive behavioral therapies, biofeedback and mindfulness meditation is a more comprehensive approach to managing pain.

Contrary to what you may have heard, the pain medicine physician isn’t simply concerned with the delivery of injections and prescription medications to block or cover pain. Rather, this is a sub-specialty field (that includes anesthesiologists, physiatrists and — yes — neurologists) that is predicated upon a thorough knowledge of how the body works and how the brain contributes to suffering from pain. The pain doctor’s ultimate goal is to get to the bottom of what’s causing the pain. It’s to learn what the brain is trying to tell us in the patient with acute or chronic pain. And then, to fix it so our patients’ pain can be eliminated, or at the very least managed in a way that allows them to continue living a healthy and fulfilling life.

[See: Your Guide to Over-the-Counter Pain Relief.]

In addition to understanding those ascending and descending pain pathways and differences between acute and chronic pain, it’s also important to know that there are other classifications of pain that aid the pain medicine physician in matching the right treatment with the type of pain being experienced. The brain is a fascinating structure, and while it’s true that all pain is in the brain, that doesn’t mean it’s a figment of your imagination. If you’re experiencing unresolved pain, talk to your doctor about having it evaluated by a skilled pain expert.

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Pain: Is it All in Your Head? originally appeared on usnews.com