The Relationship between Chronic Pain, Cognition and Executive Function

WHY PERSISTENT PAIN CAN MAKE THINKING FEEL HARDER

Chronic pain can affect more than physical comfort and movement. Some people also notice difficulty concentrating, remembering information, organising tasks, finding words or making decisions. These experiences are often described informally as “brain fog”.

Research supports an association between chronic pain and lower average performance in several areas of cognition, particularly attention, working memory, processing speed and aspects of executive function. However, the effects vary considerably between people and pain conditions. Many people with chronic pain perform normally on cognitive testing, and cognitive symptoms may also be influenced by sleep, fatigue, mood, medication and other health factors.[1,3,4,7,8]

Pain-related cognitive symptoms are real, but they do not, by themselves, indicate reduced intelligence, permanent brain injury or dementia.

WHAT ARE COGNITION AND EXECUTIVE FUNCTION?

Cognition is a broad term covering the mental processes used to understand information, learn, remember, communicate and solve problems.

Executive function refers to the higher-level skills that help us direct those processes towards a goal. It can be thought of as the brain’s management system: deciding what to do, beginning the task, staying on track, adjusting when circumstances change and checking the result.

WHAT CAN PAIN-RELATED COGNITIVE DIFFICULTY FEEL LIKE?

People may describe:

• losing their train of thought during conversations;

• reading the same paragraph several times;

• forgetting why they entered a room;

• difficulty holding several pieces of information in mind;

• taking longer to complete paperwork or familiar work tasks;

• struggling to prioritise when several things need attention;

• difficulty switching between tasks;

• feeling mentally exhausted after concentrating;

• making more mistakes during a pain flare;

• relying more heavily on lists, reminders or other people;

• finding complex decisions unusually tiring.

The pattern may fluctuate. A person might think clearly at one time of day but struggle when pain, fatigue or medication effects are greater. Tasks requiring sustained concentration, rapid decisions or frequent switching may be more difficult than familiar tasks completed at a comfortable pace.

This is often better understood as reduced cognitive efficiency under load, rather than a uniform loss of ability.

WHAT DOES THE RESEARCH SHOW?

Research findings need to be interpreted carefully.

A systematic review and meta-analysis of working memory found a moderate average difference between people with chronic pain and pain-free controls. However, the studies used many different tests and pain populations, and all were considered at high risk of bias.[3] A separate meta-analysis found small-to-moderate average differences in executive function, but again identified substantial methodological limitations.[4]

More recent reviews continue to find possible differences in memory, processing speed and executive function. For example, a 2025 review of chronic low back pain found poorer average performance in several domains, but the certainty of evidence was low or very low for most outcomes. Another 2025 review found that memory findings differed according to the type of chronic pain being studied.[7,8] Taken together, this suggests that chronic pain does not produce one predictable cognitive profile.

Research studies generally compare group averages. They cannot determine how much of an individual person’s difficulty is caused directly by pain, nor predict whether a particular person will experience cognitive symptoms.

Subjective symptoms and test results may differ

A person can experience considerable difficulty in daily life while performing adequately during a short, structured assessment.

In one fibromyalgia study, participants reported broad cognitive concerns but showed only subtle and selective differences on objective working-memory testing. Fatigue and depressive symptoms contributed to the findings.[6] This mismatch does not mean that symptoms are imagined. A quiet, time-limited test may not reproduce the competing demands, interruptions, pain fluctuations and sustained effort required during an ordinary day

WHY CAN PAIN MAKE THINKING HARDER?

There is unlikely to be one single mechanism. Several processes may operate at the same time.

1. Pain competes for attention

Pain is an attention-demanding signal. Its biological purpose includes interrupting other activity so that the body can respond to a possible threat.

When pain persists, part of the brain’s limited processing capacity may repeatedly be directed towards:

• the painful sensation itself;

• monitoring whether pain is changing;

• anticipating the next flare;

• considering whether an activity is safe;

• suppressing or coping with discomfort;

• deciding whether to stop, continue or modify an activity.

This leaves fewer mental resources available for reading, remembering instructions, solving problems or managing several tasks at once. Unpredictable or changing pain may be particularly distracting because it repeatedly demands re-evaluation.[1,2]

This does not mean that a person is deliberately focusing on pain or could simply choose to ignore it.

2. Pain and executive control use overlapping brain systems

Pain processing is not confined to a single “pain centre”. It involves networks that also participate in attention, emotion, motivation, memory and decision-making. These include areas of the prefrontal and cingulate cortex and their connections with other brain regions.[1]

Research has identified group-level differences in the function and structure of some of these networks in people with chronic pain. These findings help researchers investigate possible mechanisms, but they are not an individual diagnostic test and should not be interpreted as proof that a particular person has sustained permanent brain damage.

3. Pain creates ongoing cognitive workload

Living with chronic pain often requires extensive planning. People may need to manage appointments, medications, exercises, pacing, work demands, insurance processes, family responsibilities and uncertainty about future symptoms.

Each individual task may appear manageable, but their combined cognitive burden can be substantial. Decision-making can become particularly tiring when there is no clearly “right” option—for example, whether to continue an activity and risk a flare or stop and risk losing progress.

OTHER FACTORS CAN ADD TO THE COGNITIVE LOAD

Pain rarely occurs in isolation. Cognitive symptoms may be influenced by a combination of:

• disrupted or insufficient sleep;

• physical and mental fatigue;

• depression, anxiety or sustained stress;

• medication effects;

• changes in medication dose or timing;

• reduced activity or social engagement;

• alcohol or other substances;

• sensory problems such as reduced hearing or vision;

• hormonal, metabolic, neurological or other medical conditions;

• previous head injury;

• normal age-related change.

These contributors can interact. For example, pain may disrupt sleep, poor sleep may reduce concentration, and the resulting errors or frustration may increase stress. Separate articles on chronic pain and sleep and pain and mood can explore those relationships in more detail without assuming that either factor explains every cognitive symptom.

Some pain medicines can cause drowsiness, slowed responses or reduced concentration, particularly when treatment is commenced, doses are changed or several sedating medicines are combined. However, inadequately managed pain can also interfere with cognition, making the relationship between pain, medication and thinking difficult to separate.[10] Prescribed medicines should not be stopped or reduced abruptly without advice from the treating clinician.

WHY EXECUTIVE FUNCTION MATTERS IN PAIN MANAGEMENT

Executive skills are used throughout pain self-management. They help a person to:

• remember and attend appointments;

• understand treatment options;

• weigh potential benefits, limitations and risks;

• organise medications safely;

• plan activity and recovery periods;

• monitor symptoms without becoming overwhelmed by them;

• adapt pacing when circumstances change;

• apply rehabilitation strategies consistently;

• communicate clearly with clinicians and employers;

• manage setbacks without abandoning the overall plan.

A 2024 study of 189 chronic pain outpatients found that lower performance on several executive-function measures was modestly associated with greater everyday pain interference and lower perceived control, even after accounting for age, education and depression. Pain intensity, duration and distribution were not associated with executive performance. Because the study was observational, it cannot establish which factor caused the other.[9]

Nevertheless, the findings highlight an important practical issue: a complicated pain-management plan may become difficult to carry out when the plan itself exceeds the person’s available cognitive capacity. Difficulty following such a plan should not automatically be interpreted as poor motivation or unwillingness to participate.

IS PAIN-RELATED “BRAIN FOG” THE SAME AS DEMENTIA?

No. Pain-related cognitive symptoms are not, by themselves, a diagnosis of mild cognitive impairment or dementia.

Pain-related difficulties may fluctuate with symptom severity, sleep, fatigue, stress or medication exposure. Dementia is a clinical syndrome involving progressive cognitive decline that increasingly interferes with independent functioning. Diagnosis requires a broader assessment and cannot be made from occasional forgetfulness or a brief screening score alone.

A 2026 meta-analysis of longitudinal cohort studies found a modest association between chronic pain and subsequent dementia diagnoses. However, the studies were observational and highly heterogeneous. The association was not seen in pooled measures of general cognitive-test performance, and factors such as depression, age, vascular health, physical activity and shared medical conditions may influence the relationship. The findings therefore do not establish that chronic pain directly causes dementia.[12]

It would be misleading to suggest that people with chronic pain will inevitably develop progressive cognitive decline. However, new or steadily worsening cognitive symptoms should not simply be attributed to pain without appropriate assessment.

HOW ARE COGNITIVE SYMPTOMS ASSESSED?

There is no single test that diagnoses “pain-related brain fog”.

Assessment usually begins with understanding:

• when the symptoms began;

• whether they are stable, fluctuating or progressive;

• their relationship to pain flares, sleep and fatigue;

• whether they followed a medication change, illness or injury;

• which cognitive tasks are affected;

• whether work, driving, medication safety or independent living is being compromised;

• whether family members or colleagues have noticed a change;

• whether there are associated neurological or behavioural symptoms.

A clinician may review prescribed and non-prescribed substances, sleep, mood, hearing, vision and relevant medical conditions. Depending on the circumstances, assessment may include a physical or neurological examination, brief cognitive screening, blood tests or other investigations.

Brief screening tests can be helpful, but they have limitations. A systematic review found that chronic pain studies had used 53 different cognitive instruments and that none had been specifically validated for pain populations at that time.[5] A normal brief screen therefore does not necessarily explain away functional difficulties, while an abnormal score does not establish a diagnosis by itself.

More detailed neuropsychological assessment may be appropriate when symptoms are persistent, diagnostically unclear or substantially affecting work, study, treatment participation or independence.

WHAT MAY HELP?

There is currently no single treatment proven to reliably reverse cognitive symptoms associated with chronic pain.

A 2025 systematic review identified 12 randomised trials examining whether chronic pain treatments improved cognition. Only half reported cognitive improvement, and the pain conditions, interventions, cognitive measures and study durations varied considerably. The reviewers concluded that the available evidence could not confirm that treating pain will, by itself, improve cognition.[11]

Management is therefore usually individualised. It may combine investigation of contributing factors with practical strategies that reduce cognitive demand.

Review potentially modifiable contributors

A clinician can help review:

• whether the pain-management plan is meeting its intended functional goals;

• sleep quality and possible sleep disorders;

• fatigue and daytime alertness;

• mood and stress;

• medication timing, dose and interactions;

• hearing or vision problems;

• other medical or neurological conditions.

The aim is not to assume that one factor explains everything, but to identify contributors that may be safely addressed.

Externalise memory

Rather than relying entirely on mental recall:

• use one calendar for all appointments and deadlines;

• set reminders before, not only at, important events;

• write down instructions as they are given;

• keep a consistent location for essential items;

• use checklists for multistep activities;

• maintain an up-to-date medication list;

• use a medication organiser when clinically appropriate;

• record the next action required, rather than only the overall goal.

Using one trusted system is usually easier than maintaining several partly overlapping systems.

Reduce unnecessary cognitive load

Strategies may include:

• completing one task at a time;

• reducing background noise and interruptions;

• breaking complex work into short, defined steps;

• taking planned pauses before concentration deteriorates;

• finishing one stage before switching to another;

• limiting important decisions during severe flares or marked sedation;

• allowing more time for unfamiliar information;

• checking important work after a break.

These are compensatory strategies, not evidence that the underlying cognitive problem has been “cured”. Their purpose is to make day-to-day functioning more reliable.

Work with the pattern of symptoms

Some people identify a time of day when they are more alert or when pain is relatively manageable. More demanding activities can be scheduled for this period where practical.

A brief diary may help identify relationships between cognitive symptoms and pain flares, sleep, medication timing or overactivity. Extensive symptom monitoring can itself become burdensome, so records should be simple and directed towards a specific clinical question.

Make healthcare communication easier

During appointments, it may help to:

• bring a concise written list of priorities;

• ask for important instructions in writing;

• repeat the plan back in your own words;

• clarify which action should happen first;

• bring a support person when appropriate;

• request a simplified treatment schedule where clinically possible.

Clinicians can also reduce cognitive burden by providing clear priorities rather than several unranked recommendations at once.

Consider occupational or neuropsychological support

An occupational therapist may assist with routines, environmental modifications, fatigue management, workplace adjustments and safe completion of everyday tasks.

A neuropsychologist may help clarify the pattern of cognitive strengths and weaknesses and develop compensatory strategies. This can be particularly useful where symptoms affect complex employment, study or independent living.

WHEN SHOULD COGNITIVE CHANGE BE MEDICALLY REVIEWED?

Arrange a medical assessment when cognitive symptoms:

• are new, unexplained or becoming progressively worse;

• began after a head injury, illness or medication change;

• are noticed by family members, friends or colleagues;

• cause repeated medication errors;

• affect driving or workplace safety;

• lead to getting lost in familiar places;

• interfere with managing finances or ordinary daily responsibilities;

• include substantial changes in language, behaviour or personality.

Seek emergency assistance for sudden neurological symptoms

Sudden confusion, facial drooping, arm weakness, speech difficulty, loss of consciousness, a seizure or a sudden severe headache may indicate a medical emergency rather than chronic pain-related cognitive difficulty. In Australia, call 000 and request an ambulance, particularly where stroke symptoms are possible.

TAKE-HOME MESSAGE

Chronic pain can make thinking less efficient, particularly when a task demands sustained attention, working memory, rapid decisions or frequent switching. The effect varies considerably between people and is often influenced by fatigue, sleep, mood, medication and other health factors.

“Brain fog” does not mean that someone is unintelligent, unmotivated or inevitably developing dementia. It also should not be assumed that every cognitive symptom is caused by pain.

The most useful approach is usually to:

1. assess the individual pattern and exclude other important causes;

2. address modifiable contributors where possible;

3. simplify unnecessarily complex treatment demands;

4. use practical supports for memory, planning and communication; and

5. obtain further assessment when symptoms are progressive or affecting safety and independence.

Last medically reviewed: 27/08/2026

REFERENCES

1. Moriarty O, McGuire BE, Finn DP. The effect of pain on cognitive function: a review of clinical and preclinical research. Prog Neurobiol. 2011;93(3):385–404. doi:10.1016/j.pneurobio.2011.01.002.

2. Legrain V, Van Damme S, Eccleston C, Davis KD, Seminowicz DA, Crombez G. A neurocognitive model of attention to pain: behavioral and neuroimaging evidence. Pain. 2009;144(3):230–232. doi:10.1016/j.pain.2009.03.020.

3. Berryman C, Stanton TR, Bowering KJ, Tabor A, McFarlane A, Moseley GL. Evidence for working memory deficits in chronic pain: a systematic review and meta-analysis. Pain. 2013;154(8):1181–1196. doi:10.1016/j.pain.2013.03.002.

4. Berryman C, Stanton TR, Bowering KJ, Tabor A, McFarlane A, Moseley GL. Do people with chronic pain have impaired executive function? A meta-analytical review. Clin Psychol Rev. 2014;34(7):563–579. doi:10.1016/j.cpr.2014.08.003.

5. Ojeda B, Failde I, Dueñas M, Salazar A, Eccleston C. Methods and instruments to evaluate cognitive function in chronic pain patients: a systematic review. Pain Med. 2016;17(8):1465–1489. doi:10.1093/pm/pnv077.

6. Pidal-Miranda M, González-Villar AJ, Carrillo-de-la-Peña MT, Andrade E, Rodríguez-Salgado D. Broad cognitive complaints but subtle objective working memory impairment in fibromyalgia patients. PeerJ. 2018;6:e5907. doi:10.7717/peerj.5907.

7. Sobott N, Crowther ME, Vincent GE, et al. Chronic low back pain is associated with compromised cognitive function: a systematic review and meta-analysis. J Pain. 2025;33:105475. doi:10.1016/j.jpain.2025.105475.

8. Kelly K, Keohane E, Davy G. The effect of chronic pain on memory: a systematic review and meta-analysis exploring nociceptive, neuropathic and nociplastic pain. Brain Cogn. 2025;187:106305. doi:10.1016/j.bandc.2025.106305.

9. Berginström N, Wåhlin S, Österlund L, et al. Executive functioning is associated to everyday interference of pain in patients with chronic pain. PLoS One. 2024;19(11):e0313187. doi:10.1371/journal.pone.0313187.

10. Warner NS, Mielke MM, Verdoorn BP, et al. Pain, opioid analgesics, and cognition: a conceptual framework in older adults. Pain Med. 2023;24(2):171–181. doi:10.1093/pm/pnac113.

11. Brennecke AB, Barreto ESR, Lins-Kusterer L, Azi LMTA, Kraychete D. Impact of different treatments for chronic pain on cognitive function: a systematic review. Br J Pain. 2025;19(3):147–162. doi:10.1177/20494637241311784.

12. Qiu D, Zhou ZB, Li XY, et al. Chronic pain and risk of cognitive impairment: a meta-analysis of longitudinal cohort studies. Transl Psychiatry. 2026;16:133. doi:10.1038/s41398-026-03924-8.

This article provides general educational information and is not a substitute for individual medical assessment or advice. Cognitive symptoms may have several causes. Seek medical review for new, worsening or functionally significant symptoms, and do not change prescribed medicines without discussing this with the prescribing clinician.