PAIN MANAGEMENT IN THE EMERGENCY DEPARTMENT - A LITERATURE REVIEW
Abstract
Introduction: Pain is the most common presenting symptom in emergency departments and requires timely, accurate assessment and effective management to prevent complications and improve patient outcomes. This review focuses on the mechanisms, classification, and management strategies for acute pain in the ED, including common clinical presentations and evidence-based therapeutic approaches.
Materials and methods: A literature search was conducted in the PubMed database to find recent systematic reviews and meta-analyses on pain management in emergency medicine. Keywords included: pain, analgesics, emergency department, injury.
Results: A review of the literature indicates that pain management in emergency medicine is primarily guided by the type, cause, and severity of pain. A multimodal approach offers significant therapeutic benefits. Despite local differences in drug preferences and clinical guidelines, accurate pain assessment and the prompt, appropriate adjustment of analgesics to symptom intensity remain a fundamental principle of pain management. Equally important is the use of adjuvant therapies and non-pharmacological interventions, including psychological support, individualized care and effective communication with the patient.
Conclusion: Effective pain management in emergency settings requires a structured, patient-centered, and interdisciplinary approach. Incorporating both pharmacologic and supportive strategies not only enhances acute symptom relief but also contributes to better long-term outcomes and healthcare resource utilization.
References
Rech, M. A., Griggs, C., Lovett, S., & Motov, S. (2022). Acute pain management in the Emergency Department: Use of multimodal and non-opioid analgesic treatment strategies. The American journal of emergency medicine, 58, 57–65. https://doi.org/10.1016/j.ajem.2022.05.022
International Association for the Study of Pain. IASP announces revised definition of pain. 2020. Available from: https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/ Accessed Aug 2025.
Armstrong, S. A., & Herr, M. J. (2023). Physiology, Nociception. In StatPearls. StatPearls Publishing.
Khalid, S., & Tubbs, R. S. (2017). Neuroanatomy and Neuropsychology of Pain. Cureus, 9(10), e1754. https://doi.org/10.7759/cureus.1754
Finnerup, N. B., Kuner, R., & Jensen, T. S. (2021). Neuropathic Pain: From Mechanisms to Treatment. Physiological reviews, 101(1), 259–301. https://doi.org/10.1152/physrev.00045.2019
Sun, R., Wang, N., Mou, H., Gao, C., Yu, L., Li, W., Li, T., Huang, P., & Gong, W. (2022). Risk Factors for Poor Pain Control in Zoster-Associated Pain: A Retrospective Study. Pain and therapy, 11(4), 1471–1481. https://doi.org/10.1007/s40122-022-00426-5
Bannister, K., Sachau, J., Baron, R., & Dickenson, A. H. (2020). Neuropathic Pain: Mechanism-Based Therapeutics. Annual review of pharmacology and toxicology, 60, 257–274. https://doi.org/10.1146/annurev-pharmtox-010818-021524
Sehdev, M., Lewis, J., & Barreveld, A. (2023). Demystifying Acute Pain Management in the Emergency Department: A Case-Based Approach. MedEdPORTAL : the journal of teaching and learning resources, 19, 11339. https://doi.org/10.15766/mep_2374-8265.11339
Hachimi-Idrissi S, Coffey F, Hautz WE, Leach R, Sauter TC, Sforzi I, Dobias V. Approaching acute pain in emergency settings: European Society for Emergency Medicine (EUSEM) guidelines-part 1: assessment. Intern Emerg Med. 2020 Oct;15(7):1125-1139. doi: 10.1007/s11739-020-02477-y. Epub 2020 Sep 15. PMID: 32930965
Hsu, H. P., Cheng, M. T., Lu, T. C., Chen, Y. C., Liao, E. C., Sung, C. W., Liew, C. Q., Ling, D. A., Ko, C. H., Ku, N. W., Fu, L. C., Huang, C. H., & Tsai, C. L. (2022). Pain Assessment in the Emergency Department: A Prospective Videotaped Study. The western journal of emergency medicine, 23(5), 716–723. https://doi.org/10.5811/westjem.2022.6.55553
Karcioglu, O., Topacoglu, H., Dikme, O., & Dikme, O. (2018). A systematic review of the pain scales in adults: Which to use?. The American journal of emergency medicine, 36(4), 707–714. https://doi.org/10.1016/j.ajem.2018.01.008
Hawker, G. A., Mian, S., Kendzerska, T., & French, M. (2011). Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis care & research, 63 Suppl 11, S240–S252. https://doi.org/10.1002/acr.20543
Anekar, A. A., Hendrix, J. M., & Cascella, M. (2023). WHO Analgesic Ladder. In StatPearls. StatPearls Publishing.
Hachimi-Idrissi S, Dobias V, Hautz WE, Leach R, Sauter TC, Sforzi I, Coffey F. Approaching acute pain in emergency settings; European Society for Emergency Medicine (EUSEM) guidelines-part 2: management and recommendations. Intern Emerg Med. 2020 Oct;15(7):1141-1155. doi: 10.1007/s11739-020-02411-2. Epub 2020 Sep 15. PMID: 32930964
Kremer, M., Salvat, E., Muller, A., Yalcin, I., & Barrot, M. (2016). Antidepressants and gabapentinoids in neuropathic pain: Mechanistic insights. Neuroscience, 338, 183–206. https://doi.org/10.1016/j.neuroscience.2016.06.057
Chang W. J. (2020). Muscle Relaxants for Acute and Chronic Pain. Physical medicine and rehabilitation clinics of North America, 31(2), 245–254. https://doi.org/10.1016/j.pmr.2020.01.005
Xu, R., Nair, S. K., Shah, P. P., Kannapadi, N., Materi, J., Alomari, S., Kim, T., Kalluri, A., Xia, Y., So, R. J., Lim, M., & Bettegowda, C. (2022). A Potential Role for Steroids in Acute Pain Management in Patients with Trigeminal Neuralgia. World neurosurgery, 167, e1291–e1298. https://doi.org/10.1016/j.wneu.2022.09.025
McGuire, L. S., & Slavin, K. (2020). Revisiting the WHO Analgesic Ladder for Surgical Management of Pain. AMA journal of ethics, 22(1), E695–E701. https://doi.org/10.1001/amajethics.2020.695
Raffa, R. B., & Pergolizzi, J. V., Jr (2014). A modern analgesics pain 'pyramid'. Journal of clinical pharmacy and therapeutics, 39(1), 4–6. https://doi.org/10.1111/jcpt.12110
Vargas-Schaffer, G. (2010). Is the WHO analgesic ladder still valid? Twenty-four years of experience. Canadian Family Physician, 56(6), 514–517. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902929/
Abdel Shaheed, C., Ferreira, G. E., Dmitritchenko, A., McLachlan, A. J., Day, R. O., Saragiotto, B., Lin, C., Langendyk, V., Stanaway, F., Latimer, J., Kamper, S., McLachlan, H., Ahedi, H., & Maher, C. G. (2021). The efficacy and safety of paracetamol for pain relief: an overview of systematic reviews. The Medical journal of Australia, 214(7), 324–331. https://doi.org/10.5694/mja2.50992
Pergolizzi, J. V., Magnusson, P., LeQuang, J. A., Breve, F., Taylor, R., Wollmuth, C., & Varrassi, G. (2021). Can NSAIDs and Acetaminophen Effectively Replace Opioid Treatment Options for Acute Pain?. Expert opinion on pharmacotherapy, 22(9), 1119–1126. https://doi.org/10.1080/14656566.2021.1901885
Cattin, G., Jenvrin, J., Hardouin, J. B., Longo, C., & Montassier, E. (2022). Intravenous acetaminophen with morphine versus intravenous morphine alone for acute pain in the emergency room: protocol for a multicenter, randomized, placebo-controlled, double-blinded study (ADAMOPA). Trials, 23(1), 1016. https://doi.org/10.1186/s13063-022-06943-0
Maurice-Szamburski, A., Quemeneur, C., Rozier, R., Cuvillon, P., & Ecoffey, C. (2025). Intravenously Administered Nonsteroidal Anti-Inflammatory Drugs in Clinical Practice: A Narrative Review. Pharmacy (Basel, Switzerland), 13(1), 18. https://doi.org/10.3390/pharmacy13010018
Khankhel, N., Friedman, B. W., Baer, J., Lopez, L., Feliciano, C., Lee, S., & Irizarry, E. (2024). Topical Diclofenac Versus Oral Ibuprofen Versus Diclofenac + Ibuprofen for Emergency Department Patients With Acute Low Back Pain: A Randomized Study. Annals of emergency medicine, 83(6), 542–551. https://doi.org/10.1016/j.annemergmed.2024.01.037
Boblewska, J., & Dybowski, B. (2023). Methodology and findings of randomized clinical trials on pharmacologic and non-pharmacologic interventions to treat renal colic pain - a review. Central European journal of urology, 76(3), 212–226. https://doi.org/10.5173/ceju.2023.92
Stamer, U. M., Gundert-Remy, U., Biermann, E., Erlenwein, J., Meiβner, W., Wirz, S., & Stammschulte, T. (2017). Metamizol : Überlegungen zum Monitoring zur frühzeitigen Diagnose einer Agranulozytose [Dipyrone (metamizole) : Considerations on monitoring for early detection of agranulocytosis]. Schmerz (Berlin, Germany), 31(1), 5–13. https://doi.org/10.1007/s00482-016-0160-3
Shah R. R. (2019). Metamizole (dipyrone)-induced agranulocytosis: Does the risk vary according to ethnicity?. Journal of clinical pharmacy and therapeutics, 44(1), 129–133. https://doi.org/10.1111/jcpt.12768
Miotto, K., Cho, A. K., Khalil, M. A., Blanco, K., Sasaki, J. D., & Rawson, R. (2017). Trends in Tramadol: Pharmacology, Metabolism, and Misuse. Anesthesia and analgesia, 124(1), 44–51. https://doi.org/10.1213/ANE.0000000000001683
Firouzian, A., Alipour, A., Rashidian Dezfouli, H., Zamani Kiasari, A., Gholipour Baradari, A., Emami Zeydi, A., Amini Ahidashti, H., Montazami, M., Hosseininejad, S. M., & Yazdani Kochuei, F. (2016). Does lidocaine as an adjuvant to morphine improve pain relief in patients presenting to the ED with acute renal colic? A double-blind, randomized controlled trial. The American journal of emergency medicine, 34(3), 443–448. https://doi.org/10.1016/j.ajem.2015.11.062
Wicks, C., Hudlicky, T., & Rinner, U. (2021). Morphine alkaloids: History, biology, and synthesis. The Alkaloids. Chemistry and biology, 86, 145–342. https://doi.org/10.1016/bs.alkal.2021.04.001
Zhuang, Y., Wang, Y., He, B., He, X., Zhou, X. E., Guo, S., Rao, Q., Yang, J., Liu, J., Zhou, Q., Wang, X., Liu, M., Liu, W., Jiang, X., Yang, D., Jiang, H., Shen, J., Melcher, K., Chen, H., Jiang, Y., … Xu, H. E. (2022). Molecular recognition of morphine and fentanyl by the human μ-opioid receptor. Cell, 185(23), 4361–4375.e19. https://doi.org/10.1016/j.cell.2022.09.041
Kelly, E., Sutcliffe, K., Cavallo, D., Ramos-Gonzalez, N., Alhosan, N., & Henderson, G. (2023). The anomalous pharmacology of fentanyl. British journal of pharmacology, 180(7), 797–812. https://doi.org/10.1111/bph.15573
Ma, X., Yan, J., & Jiang, H. (2023). Application of Ketamine in Pain Management and the Underlying Mechanism. Pain research & management, 2023, 1928969. https://doi.org/10.1155/2023/1928969
Motov, S., Rosenbaum, S., Vilke, G. M., & Nakajima, Y. (2016). Is There a Role for Intravenous Subdissociative-Dose Ketamine Administered as an Adjunct to Opioids or as a Single Agent for Acute Pain Management in the Emergency Department?. The Journal of emergency medicine, 51(6), 752–757. https://doi.org/10.1016/j.jemermed.2016.07.087
Motov, S., Mann, S., Drapkin, J., Butt, M., Likourezos, A., Yetter, E., Brady, J., Rothberger, N., Gohel, A., Flom, P., Mai, M., Fromm, C., & Marshall, J. (2019). Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial. The American journal of emergency medicine, 37(2), 220–227. https://doi.org/10.1016/j.ajem.2018.05.030
Zodda D, Procopio G, Gupta A. Evaluation and management of life-threatening headaches in the emergency department. Emerg Med Pract. 2019 Feb;21(2):1-20. Epub 2019 Feb 1. PMID: 30676714.
Longoni M, Agostoni EC. Headache in neurological emergency. Neurol Sci. 2020 Dec;41(Suppl 2):409-416. doi: 10.1007/s10072-020-04761-3. PMID: 33001406.
Kelly AM, Kuan WS, Chu KH, Kinnear FB, Keijzers G, Karamercan MA, Klim S, Wijeratne T, Kamona S, Graham CA, Body R, Roberts T, Horner D, Laribi S; and the HEAD Study Group. Epidemiology, investigation, management, and outcome of headache in emergency departments (HEAD study)-A multinational observational study. Headache. 2021 Nov;61(10):1539-1552. doi: 10.1111/head.14230. Epub 2021 Nov 2. PMID: 34726783.
Do TP, Remmers A, Schytz HW, Schankin C, Nelson SE, Obermann M, Hansen JM, Sinclair AJ, Gantenbein AR, Schoonman GG. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019 Jan 15;92(3):134-144. doi: 10.1212/WNL.0000000000006697. Epub 2018 Dec 26. PMID: 30587518; PMCID: PMC6340385.
Miller NE, Rushlow D, Stacey SK. Diagnosis and Management of Sodium Disorders: Hyponatremia and Hypernatremia. Am Fam Physician. 2023 Nov;108(5):476-486. PMID: 37983699.
Dyckhoff-Shen S, Koedel U, Pfister HW, Klein M. SOP: emergency workup in patients with suspected acute bacterial meningitis. Neurol Res Pract. 2021 Jan 7;3(1):2. doi: 10.1186/s42466-020-00098-6. PMID: 33499920; PMCID: PMC7791806.
Runde D. Calculated decisions: Canadian CT head injury/trauma rule. Emerg Med Pract. 2020 Aug 15;22(Suppl 8):CD5-CD6. PMID: 32805099.
Membrilla JA, Alpuente A, Gómez-Dabo L, Raúl GY, Mariño E, Díaz-de-Terán J, Pozo-Rosich P. "Code Headache": Development of a protocol for optimizing headache management in the emergency room. Eur J Neurol. 2024 Dec;31(12):e16484. doi: 10.1111/ene.16484. Epub 2024 Sep 17. PMID: 39287050; PMCID: PMC11555131.
Burch R. Acute Treatment of Migraine. Continuum (Minneap Minn). 2024 Apr 1;30(2):344-363. doi: 10.1212/CON.0000000000001402. PMID: 38568487.
Ashina S, Mitsikostas DD, Lee MJ, Yamani N, Wang SJ, Messina R, Ashina H, Buse DC, Pozo-Rosich P, Jensen RH, Diener HC, Lipton RB. Tension-type headache. Nat Rev Dis Primers. 2021 Mar 25;7(1):24. doi: 10.1038/s41572-021-00257-2. PMID: 33767185.
Mauro C, Vriz O, Romano L, Citro R, Russo V, Ranieri B, Alamro B, Aladmawi M, Granata R, Galzerano D, Bellino M, Cocchia R, Mehta RM, Dellegrottaglie S, Alsergani H, Mehta RH, Bossone E. Imaging Cardiovascular Emergencies: Real World Clinical Cases. Heart Fail Clin. 2020 Jul;16(3):331-346. doi: 10.1016/j.hfc.2020.03.003. PMID: 32503756.
Ayloo A, Cvengros T, Marella S. Evaluation and treatment of musculoskeletal chest pain. Prim Care. 2013 Dec;40(4):863-87, viii. doi: 10.1016/j.pop.2013.08.007. PMID: 24209723.
Jany B. Pneumologische Ursachen für Thoraxschmerz [Pulmonary causes of chest pain]. Internist (Berl). 2017 Jan;58(1):22-28. German. doi: 10.1007/s00108-016-0169-9. PMID: 27986981.
Masarapu V, Xia E, Son H. Esophageal emergencies: another important cause of acute chest pain. Insights Imaging. 2020 Oct 9;11(1):109. doi: 10.1186/s13244-020-00915-1. PMID: 33034721; PMCID: PMC7547061.
Fazekas D, Doroshenko M, Horn DB. Intercostal Neuralgia. 2023 Aug 14. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 32809700.
Meuret AE, Tunnell N, Roque A. Anxiety Disorders and Medical Comorbidity: Treatment Implications. Adv Exp Med Biol. 2020;1191:237-261. doi: 10.1007/978-981-32-9705-0_15. PMID: 32002933.
Kontos MC, de Lemos JA. Chest Pain in the Emergency Department: Chasing Perfection. J Am Coll Cardiol. 2024 Apr 2;83(13):1191-1193. doi: 10.1016/j.jacc.2024.02.018. Epub 2024 Mar 25. PMID: 38538197.
DeLaney MC, Neth M, Thomas JJ. Chest pain triage: Current trends in the emergency departments in the United States. J Nucl Cardiol. 2017 Dec;24(6):2004-2011. doi: 10.1007/s12350-016-0578-0. Epub 2016 Sep 8. PMID: 27638744.
Reed MJ. Diagnosis and management of acute aortic dissection in the emergency department. Br J Hosp Med (Lond). 2024 Apr 30;85(4):1-9. doi: 10.12968/hmed.2023.0366. PMID: 38708978.
Fichtner, A., Schrofner-Brunner, B., Magath, T., Mutze, P., & Koch, T. (2023). Regional Anesthesia for Acute Pain Treatment in Pre-Hospital and In-Hospital Emergency Medicine. Deutsches Arzteblatt international, 120(48), 815–822. https://doi.org/10.3238/arztebl.m2023.0221
Guaiana, G., Meader, N., Barbui, C., Davies, S. J., Furukawa, T. A., Imai, H., Dias, S., Caldwell, D. M., Koesters, M., Tajika, A., Bighelli, I., Pompoli, A., Cipriani, A., Dawson, S., & Robertson, L. (2023). Pharmacological treatments in panic disorder in adults: a network meta-analysis. The Cochrane database of systematic reviews, 11(11), CD012729. https://doi.org/10.1002/14651858.CD012729.pub3
Yew, K. S., George, M. K., & Allred, H. B. (2023). Acute Abdominal Pain in Adults: Evaluation and Diagnosis. American family physician, 107(6), 585–596.
Liljekvist, M. S., Pommergaard, H. C., Burcharth, J., & Rosenberg, J. (2015). Billeddannende undersøgelser ved akut opståedemavesmerter [Diagnostic imaging and acute abdominal pain]. Ugeskrift for laeger, 177(4), V06140339.
Prasad, S., Hood, C. M., Young, C., Hirsch, J. A., Saini, S., Sodickson, A. D., Lev, M. H., Raja, A. S., Gee, M. S., Whitehead, D. C., & Succi, M. D. (2025). Computed Tomographic Angiography and Yield for Gastrointestinal Bleeding in the Emergency Department. JAMA network open, 8(8), e2529746. https://doi.org/10.1001/jamanetworkopen.2025.29746
Keisler, B., & Carter, C. (2015). Abdominal aortic aneurysm. American family physician, 91(8), 538–543.
Dash, A., Maiti, R., Akantappa Bandakkanavar, T. K., & Arora, P. (2012). Intramuscular drotaverine and diclofenac in acute renal colic: a comparative study of analgesic efficacy and safety. Pain medicine (Malden, Mass.), 13(3), 466–471. https://doi.org/10.1111/j.1526-4637.2011.01314.x
Rowland, K. D., Fuehrer, J., Motov, S. M., Vilke, G., Rosenbaum, S. B., & Quenzer, F. (2020). Should Antiemetics be Given Prophylactically with Intravenous Opioids While Treating Acute Pain in the Emergency Department?: Clinical Practice Paper Approved by American Academy of Emergency Medicine Clinical Guidelines Committee. The Journal of emergency medicine, 58(4), 706–709. https://doi.org/10.1016/j.jemermed.2019.12.024
Barkun, A. N., Almadi, M., Kuipers, E. J., Laine, L., Sung, J., Tse, F., Leontiadis, G. I., Abraham, N. S., Calvet, X., Chan, F. K. L., Douketis, J., Enns, R., Gralnek, I. M., Jairath, V., Jensen, D., Lau, J., Lip, G. Y. H., Loffroy, R., Maluf-Filho, F., Meltzer, A. C., … Bardou, M. (2019). Management of Nonvariceal Upper Gastrointestinal Bleeding: Guideline Recommendations From the International Consensus Group. Annals of internal medicine, 171(11), 805–822. https://doi.org/10.7326/M19-1795
DePalma M. G. (2020). Red flags of low back pain. JAAPA : official journal of the American Academy of Physician Assistants, 33(8), 8–11. https://doi.org/10.1097/01.JAA.0000684112.91641.4c
Wirth, B., & Schweinhardt, P. (2024). Personalized assessment and management of non-specific low back pain. European journal of pain (London, England), 28(2), 181–198. https://doi.org/10.1002/ejp.2190
Abril, L., Zamora, C., Cordero, M., Williams, A. R., & Friedman, B. W. (2022). The Relative Efficacy of Seven Skeletal Muscle Relaxants. An Analysis of Data From Randomized Studies. The Journal of emergency medicine, 62(4), 455–461. https://doi.org/10.1016/j.jemermed.2021.09.025
Ashbrook, J., Rogdakis, N., Callaghan, M. J., Yeowell, G., & Goodwin, P. C. (2020). The therapeutic management of back pain with and without sciatica in the emergency department: a systematic review. Physiotherapy, 109, 13–32. https://doi.org/10.1016/j.physio.2020.07.005
Fabbri, A., Voza, A., Riccardi, A., Serra, S., Iaco, F., & Study and Research Center of the Italian Society of Emergency Medicine (SIMEU) (2023). The Pain Management of Trauma Patients in the Emergency Department. Journal of clinical medicine, 12(9), 3289. https://doi.org/10.3390/jcm12093289
Gleber, R., Vilke, G. M., Castillo, E. M., Brennan, J., Oyama, L., & Coyne, C. J. (2020). Trends in emergency physician opioid prescribing practices during the United States opioid crisis. The American journal of emergency medicine, 38(4), 735–740. https://doi.org/10.1016/j.ajem.2019.06.011
Motov, S. M., & Nelson, L. S. (2016). Advanced Concepts and Controversies in Emergency Department Pain Management. Anesthesiology clinics, 34(2), 271–285. https://doi.org/10.1016/j.anclin.2016.01.006
Copyright (c) 2025 Michał Szalach, Aleksandra Żywicka, Zuzanna Rabczak, Marcin Narloch, Kamila Mozga, Mateusz Jasiński, Małgorzata Kuczek, Jakub Rusek, Justyna Tasior, Bartosz Burda
This work is licensed under a Creative Commons Attribution 4.0 International License.
All articles are published in open-access and licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0). Hence, authors retain copyright to the content of the articles.
CC BY 4.0 License allows content to be copied, adapted, displayed, distributed, re-published or otherwise re-used for any purpose including for adaptation and commercial use provided the content is attributed.
