ORIGINAL ARTICLE

Morning types are less sensitive to pain than evening types all
day long
K.S. Jankowski
Faculty of Psychology, University of Warsaw, Poland

Correspondence Abstract
Konrad S. Jankowski
E-mail: konrad.jankowski@psych.uw.edu.pl Background: Diurnal variations in pain have been observed in
experimental protocols, post-surgery states and pathological conditions.
Funding Sources Chronotype is considered to have the most profound effect on diurnal
Manuscript preparation was partially
variations, and in addition, previous studies suggest that evening types
supported by the grant 2011/03/D/HS6/05760
from the National Science Centre, Poland.
may be more vulnerable to pain than morning types. This study aimed to
examine whether or not morning and evening chronotypes differ in terms
Conflict of interest of their daily levels and diurnal fluctuations of pain sensitivity.
None declared. Methods: A total of 16 morning-healthy and 15 evening-healthy men
were selected using the Morningness-Eveningness Questionnaire and
Accepted for publication underwent nine measurements during 1 day (between 08:15 and 20:15 h),
7 December 2012
each consisting of five heat stimuli situated at the ventral side of the wrist.
doi:10.1002/j.1532-2149.2012.00274.x
Results: A marked difference between chronotypes was found, with
morning types showing less sensitivity to pain than evening types all day
long [M = 50.1; standard error (SE) = 1 and M = 47.2; SE = 1, respectively;
pain thresholds in centigrade]. Diurnal variations in pain were not
statistically significant.
Conclusions: The results showed that chronotype could be an important
factor determining sensitivity to pain, regardless of time of day.

Horne and Östberg (1976). It has been shown that

1. Introduction
Factors influencing pain are of great interest to
researchers and clinicians, as the anticipation of pain
symptoms can increase the accuracy of pain manage-
ment. One of these factors is the circadian rhythm.
Circadian and diurnal variations in pain have been
observed in pathological conditions (Junker and Wirz,
2010), post-surgery states (Chassard and Bruguerolle,
2004) and experimental protocols conducted on
healthy individuals (Koch and Raschka, 2004).
Some individual differences in circadian variations
in pain have been observed (Junker and Wirz, 2010);
however, they have not been ascribed to particular
individual characteristics. Chronotype describes pref-
erences for activity at specified times of the day and
is considered to have the most profound effect on
circadian rhythms; usually is assessed by question-
naires, particularly the most frequently used is the
Morningness-Eveningness Questionnaire (MEQ) by
chronotype is influenced by polymorphisms in par-
ticular genes (Wulff et al., 2009), and that genetic
factors explain 45% of the variance in morningness-
eveningness (Hur, 2007). Moreover, chronotype is
determined biologically, mostly by age; during adoles-
cence, a shift towards eveningness is observed, but
there is a morningness preference from early adult-
hood to old age (Roenneberg et al., 2007). In general,
particular phases of the circadian rhythm occur earlier
in morning types (M-types) than in evening types
(E-types). Differences between chronotypes in terms
of the pattern of circadian or diurnal variations have
been shown for many physiological and psychological
variables. A particularly robust difference occurs
regarding the phase of subjective energy, which con-
sists of greater subjective energy in the evening for
E-types and in the morning for M-types (Jankowski
and Ciarkowska, 2008; Ottoni et al., 2011). Moreover,
chronotypes assessed by the MEQ show differences in

1068 Eur J Pain 17 (2013) 1068–1073 © 2013 European Federation of International Association for the Study of Pain Chapters
K.S. Jankowski
What is already known about this topic?
• Diurnal variations in pain have been observed.
Chronotype is considered to have the most pro-
found effect on diurnal variations. Previous
studies suggest that evening types may be more
vulnerable to pain than morning types.
What does this study add?
• Morning types showed less sensitivity to pain
than evening types all day long.
• Diurnal variations in pain were statistically
non-significant.
• Chronotype could be an important factor deter-
mining sensitivity to pain, regardless of time of
day.
the timing of the peak of the core body temperature
(which is the most endogenous circadian rhythm), in
cortisol (Bailey and Heitkemper, 2001) and melatonin
(Gibertini et al., 1999) and in other physiological
rhythms (Kerkhof, 1985). Moreover, there are conse-
quent differences between chronotypes assessed by
MEQ in affective functioning consisting of disadvan-
tageous mood (Jankowski and Ciarkowska, 2008),
depressiveness and anxiety (Gaspar-Barba et al., 2009;
Pabst et al., 2009) related to eveningness. Therefore, it
is not surprising that E-types may be more vulnerable
to pain than M-types, irrespective of the time of day.
For instance, eveningness has been suggested to be
associated with headaches (Bruni et al., 2008) and
abdominal pain symptoms in adolescent girls (Negriff
and Dorn, 2009). Nonetheless, to date, no controlled
experimental study has been conducted to examine
the role of chronotype in diurnal variations in pain or
in sensitivity to pain regardless of the time of day.
Thus, the aim of the present study was to examine
whether or not M-types and E-types differed in pain
sensitivity in terms of their daily levels and diurnal
fluctuations. It was hypothesized that M-types were
less sensitive to pain than E-types. Regarding the time-
of-day effect, a directional hypothesis was not stated as
the studies on diurnal variations in pain sensitivity
using healthy volunteers showed contradictory results
(Koch and Raschka, 2004; Bachmann et al., 2011).
2. Methods
2.1 Subjects
To avoid any effects of gender, oral contraceptive use
or the menstrual cycle phase on the subjects’ pain
Eur J Pain 17 (2013) 1068–1073 © 2013 European Federation of International Association for the Study of Pain Chapters
Chronotype and pain
perception, only men were enrolled into the study.
The participants were selected from a cohort of 483
Warsaw college students, between 18 and 30 years of
age, on the basis of their morningness-eveningness
scores derived from the Polish adaptation of the MEQ
of Horne and Östberg (1976). All participants had
good health and did not use any medicine. The Polish
adaptation of the MEQ has 21 items comprising a
morningness-eveningness continuum, with higher
scores indicating greater morningness and lower ones
indicating greater eveningness. The Polish version of
the MEQ has good psychometric properties: internal
consistency reliability using the Cronbach’s alpha was
0.825, the test–retest reliability was 0.793 at a
6-month interval and 0.838 at 3 months, while valid-
ity was demonstrated by the expected relationships
between morningness-eveningness scores and both
age and diurnal fluctuations in subjective energy
(Jankowski and Ciarkowska, 2008).
In the present study, the M-types were those who
scored from z ⱖ 1.5 upwards, while the E-types were
those who scored z ⱕ -1.5, compared with the MEQ
score distribution in the Polish normalization group
(n = 9226). Sixteen subjects were categorized into the
M-type group [mean age = 23.4 ⫾ standard deviation
(SD) = 2.48 years] and 15 into the E-type group
(mean age = 22.3 ⫾ SD = 1.89 years); the two groups
did not differ in terms of age [t(29) = 1.305; p = 0.202].
The 31 subjects who underwent pain measurements
were paid for their participation. Each subject pro-
vided written informed consent, and the study was
carried out in accordance with the ethical standards of
the University of Warsaw and International Associa-
tion for the Study of Pain’s guidelines for pain research
in humans.
2.2 Pain measurements
A repeated-measures experimental design was used
with selected subjects examined on a single day. Par-
ticipants were asked to come to the laboratory nine
times during 1 day to perform the experimental task
(from 08:00 to 20:00 h). The experimental task was
the same at each time during the day and consisted of
heat-pain threshold measurements using the method
of limits (Yarnitsky et al., 1995). Pain was measured
using a 30 ¥ 30 mm Peltier device (Andrex, Warsaw,
Poland). Temperature was monitored at the probe–
skin interface by a built-in temperature sensor. The
probe was designed to fasten onto the ventral side
(ventrum) of the wrist. The probe was initially set at
37 °C to shorten the anticipation period, because only
the heat-pain threshold but not the warmth-detection
1069
Chronotype and pain K.S. Jankowski

threshold was measured; the probe was then heated at

0.5 °C/s. The subjects were able to cool the probe
down by 2 °C/s by pressing a button, and the cut-off
temperature was set at 59 °C. The thermal apparatus
was connected to a PC. Prior to heat stimulation, a
15-min resting period was allowed. To increase the
reliability of the measurements, each task at each time
of the day involved five heat stimuli with 30-s inter-
vals between the cessation of one stimulus and the
start of the next (Gustorff et al., 2003). The subjects
were asked to press a button as soon as the sensation
became unpleasant. The temperature value at which a
subject pressed the button was defined as the pain
threshold.
It should be noted that the instructions in heat-pain
threshold measurements using the method of limits
could be categorized into two groups. In the first cat-
egory, subjects are asked to stop the heat stimulus as Figure 1 Levels of the heat pain threshold (mean ⫾ standard error) in
soon as they feel it turning from hot to painful (e.g., morning (squares) and evening types (circles) throughout a day.
Schaffner et al., 2008). In the second group, subjects
are instructed to stop the increase in temperature as
soon as the perception of heat becomes unpleasant Kolmogorov–Smirnov test. Results of p < 0.05 were
(e.g., Gustorff et al., 2001, 2002, 2003). This slight considered statistically significant. The analyses were
difference in instructions could potentially impact the performed using Statistical Package for the Social Sci-
experiment results. Namely, using a word ‘pain’ or ences 18 for Windows (SPSS Inc., Chicago, IL, USA).
‘painful’ is more likely to evoke a nocebo effect (for a
comprehensive review, see Benedetti et al., 2007).
3. Results
Therefore, using terms relating to pain may evoke
anxiety and negative expectations to perceived stimu- Regarding pain threshold, the ANOVA revealed a main
lus, which in turn leads to a lowered pain threshold effect of chronotype [F(1, 29) = 4.447; p < 0.05; hp2 =
contaminated by a nocebo effect. Moreover, as a 0.133, see Fig. 1]. Neither main effect of time of day
nocebo evokes anxiety, the instructions relating to [F(8, 232) = 2.052; p = 0.089; hp2 = 0.066; e = 0.518] nor
pain should be particularly avoided if the groups being interaction between chronotype and time of day
compared in the pain thresholds could also differ in [F(8, 232) = 1.001; p = 0.412; hp2 = 0.033; e = 0.518] were
their readiness to start becoming anxious. As discussed significant.
in the Introduction section, such a difference exists The effect of chronotype explained 13.3% of the
between M-types and E-types; the former chronotypes variance in the pain threshold and was due to higher
exhibit lower anxiety and advantageous affective pain thresholds in the M-types [M = 50.087; standard
functioning. error (SE) = 0.957] than the E-types (M = 47.186;
SE = 0.988). This means that the E-types were more
sensitive to heat pain than the M-types all day long
2.3 Statistical analyses
(see Fig. 1).
The dependent variable was pain threshold in centi-
grade, averaged across five stimuli. Two-way analysis
4. Discussion and conclusions
of variance (ANOVA) with repeated measures was
used, with chronotype (two levels: M-type, E-type) as The results of this study indicate that chronotype
the between-subjects factor and time of day (nine affected the heat-pain threshold. The M-types showed
levels: 08:15, 09:45, 11:15, 12:45, 14:15, 15:45, 17:15, a higher heat-pain threshold than the E-types all day
18:45, 20:15 h) as the within-subjects factor. Partial long. This means that the M-types seemed to be less
eta-squared was used as the effect size measure and sensitive to heat pain than the E-types during the day.
Huynh–Feldt epsilon was applied if the sphericity Moreover, both the time of day and the interaction
assumption was violated. The assumption of normality between chronotype and time of day were non-
was met for all measurements as determined by the significant. This means that a lack of diurnal variation

1070 Eur J Pain 17 (2013) 1068–1073 © 2013 European Federation of International Association for the Study of Pain Chapters
K.S. Jankowski
in pain sensitivity was observed in the two chronotype
groups. This finding is in agreement with the results in
a study by Bachmann et al. (2011), where the laser-
induced heat-pain threshold did not show any diurnal
variations. However, it is also possible that the sample
size in the present study was insufficient to detect any
statistically significant time-of-day effect. Visual
inspection of pain thresholds throughout the day sug-
gests that there may be diurnal fluctuations. Never-
theless, the absence of a time-of-day effect does not
exclude the possibility that strong circadian pattern in
heat-pain sensitivity could occur (Portaluppi et al.,
2011). It may be possible that robust day-to-night
differences in heat-pain sensitivity exist that cannot be
recorded over a 12-h period, which seems ecologically
valid, as diurnal recording reflects the waking period
of the circadian rhythm of humans.
Several possible mechanisms could be suggested to
explain the observation of M-types showing a higher
heat-pain threshold than the E-types. The first could
be associated with affective functioning. Generally,
negative affective states have disadvantageous effects
on pain perception, both in healthy individuals and in
individuals with pathological conditions (Jansen,
2002; Pressman and Cohen, 2005; Rhudy and Will-
iams, 2006; Haukka et al., 2011; Knudsen et al.,
2011). Hence, emotional processing seems to have a
key role in pain perception (e.g., Schackman et al.,
2011). In previous studies, M-types, as compared with
E-types, generally reported advantageous psychologi-
cal functioning (Jankowski, 2012a,b), a better mood
profile during the course of the day (Matthews, 1988;
Jankowski and Ciarkowska, 2008) and lower depres-
siveness (Chelminski et al., 1999; Pabst et al., 2009).
Therefore, lower pain sensitivity in M-types, as com-
pared with E-types, could partly be associated with
affective functioning.
The second mechanism could be linked to differ-
ences between M-types and E-types in the circadian
pattern of cortisol. It was recently found that E-types
showed lower cortisol levels during the day (Ogińska
et al., 2010) and attenuated cortisol awakening
response (CAR) (Randler and Schaal, 2010) than
M-types. On the other hand, men who had lower
levels of salivary cortisol prior to pain induction
reported greater pain sensitivity (al’Absi et al., 2002),
and the attenuated CAR was associated with greater
levels of experimentally induced pain in both men and
women (Mayes et al., 2009). Therefore, the observa-
tion in the present study that M-types are less sensitive
to pain than E-types may also be due to the differences
between chronotypes in terms of the circadian cortisol
profile.
Eur J Pain 17 (2013) 1068–1073 © 2013 European Federation of International Association for the Study of Pain Chapters
Chronotype and pain
The third mechanism could be linked to differences
in the sleep debt between chronotypes. Namely,
E-types report shorter periods of sleep duration
during work days compared with M-types (Roepke
and Duffy, 2010), which is associated with social
demands. As a consequence, they accumulate a sleep
debt and attempt to make up for lost sleep during
weekends, while sleep deprivation is known to
heighten pain sensitivity (e.g., Campbell et al., 2011).
The present study has several limitations. These
mainly arise from the nature of the sample and the
stimulus used. Regarding the nature of the sample,
due to the small number of young adult men assessed
in this study, generalization of the results should be
made cautiously. The results of previous studies con-
cerning gender differences in the pain threshold sug-
gested that there were no such differences (Schaffner
et al., 2008), especially for thermal pain threshold
(Kindler et al., 2011), or that women are more sensi-
tive to pain than men (Rolke et al., 2006; Fillingim
et al., 2009). Furthermore, the sample subjects
included in the present study were 18–30 years of age,
whereas it was previously found by some researchers
that subjects above 40 years old are less sensitive to
experimentally induced pain (Rolke et al., 2006).
Thus, including women and older subjects should be
considered in future research on morningness-
eveningness and circadian variations in pain. Regard-
ing the stimulus used in the study, it should be noted
that the heat-pain threshold mainly represents C-fibre
functioning (Rolke et al., 2006) and various types of
pain may have distinct circadian or daily patterns.
Therefore, future studies on chronotype and the time
of day should concentrate on the pain perceived by
patients with various diseases and healthy human
subjects in different pain models.
Interestingly, in the present research, the individu-
als, particularly the M-types, seemed to exhibit higher
pain thresholds than in previous studies (e.g., Rolke
et al., 2006). One possible explanation of this finding
could be the methodology used: the starting tempera-
ture of the probe was set at a value higher than 32 °C
– the starting temperature usually used in quantitative
sensory testing – because the aim was to test only the
pain threshold and not the warmth-detection thresh-
old. One could speculate whether the higher starting
temperature resulted in a higher pain threshold. Pre-
vious studies have shown that an alteration of the
adaptation temperature mostly influences the
warmth-detection threshold and not the heat-pain
threshold (Kojo and Pertovaara, 1987; Pertovaara
et al., 1996). Moreover, when referring pain thresh-
olds obtained in the present study to those reported
1071
Chronotype and pain
from other laboratories, the thermode size should be
considered (9 cm2 for the present study), as the
smaller the thermode, the higher heat-pain thresholds
appear (Defrin and Urca, 1996; Zhu and Lu, 2010).
However, taking into account the fact that only men
were enrolled in the study, the pain thresholds
obtained for the E-types seem to fall into the range of
psychophysical thresholds for heat pain (Maudreli
et al., 2003; Rolke et al., 2006). Thus, it is possible that
a psychophysical specificity of M-types results in
heightened heat-pain thresholds.
In summary, the current results showed that chro-
notype could be an important factor determining sen-
sitivity to pain. If this finding also proves to be valid in
other healthy subjects, in pathological states and post-
surgical conditions, it may have great impact on pain
management where, depending on an individual’s
chronotype, more adequate doses of analgesics could
be administered.
Acknowledgements
The experimental protocol was supervised by Prof. Wanda
Ciarkowska.
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