REVIEwS

Neocortical circuits in pain and

pain relief
Linette Liqi Tan ✉ and Rohini Kuner    ✉
Abstract | The sensory, associative and limbic neocortical structures play a critical role in shaping
incoming noxious inputs to generate variable pain perceptions. Technological advances in tracing
circuitry and interrogation of pathways and complex behaviours are now yielding critical knowledge
of neocortical circuits, cellular contributions and causal relationships between pain perception and
its abnormalities in chronic pain. Emerging insights into neocortical pain processing suggest the
existence of neocortical causality and specificity for pain at the level of subdomains, circuits and
cellular entities and the activity patterns they encode. These mechanisms provide opportunities
for therapeutic intervention for improved pain management.

Chronic pain is often poorly managed by existing treat-
ments and is a major health care problem worldwide
with substantial clinical, social and economic impact.
A major challenge in understanding pain is due to
its multidimensionality: pain is a unique experience
involving sensory, emotional, motivational and affective
components.
The overall experience of pain is the result of col-
lective activity arising from numerous areas across the
brain in conjunction with ascending and descending
pathways1–3. However, given the wide nature of brain
areas activated during pain, as well as the logic that acti-
vation does not necessarily indicate a causal contribu-
tion, disentangling the identity of regions and pathways
that primarily mediate acute and chronic pain from
those that are secondarily recruited as a consequence
of pain or the resulting motor or emotional conse-
quences is a challenge4. This caveat is beginning to be
successfully overcome with the aid of animal models,
propelled largely by advances in a rapidly expanding
array of technologies, such as optogenetic and chemoge-
netic activation or silencing of neurons and their axonal
projections, dynamic in vivo analysis of cellular activ-
ity using single-​photon or multiphoton calcium imag-
ing, and electrophysiological analyses of the activity of
hundreds of neurons at the network level as well as the
single-​cell level5.
Several recent reviews have comprehensively dis-
Institute of Pharmacology, cussed progress made in our understanding of spinal
Heidelberg University, and subcortical brain circuits and networks5–8. However,
Heidelberg, Germany. the neocortex and its modulation of key subcortical
✉e-​mail: linette.tan@
domains has remained one of the final frontiers in pain
pharma.uni-​heidelberg.de;
research, perhaps owing to its tremendous complexity
rohini.kuner@
pharma.uni-​heidelberg.de and plasticity. Although mapping sensory processing
https://doi.org/10.1038/ has traditionally dominated our understanding of pain
s41583-021-00468-2 mechanisms, it is now well established that sensory
inputs are only poorly related to the resulting unpleas-
ant quality of pain sensation and that the experience
of pain is markedly modulated by cognitive and moti-
vational factors as well as emotional states2,3,9, thereby
highlighting the importance of neocortical contribu-
tions. This explains major individual-​dependent and
context-​dependent variations in pain sensitivity, and also
provides a basis for pain control. In support, converging
lines of evidence point to the neocortex as a central regu­
lator of diverse cortical and subcortical regions that are
involved in pain as well as its control by pharmacological
and cognitive modulation therapies3,8,9. Recent studies
have intensified the quest to understand how specificity
and functional integration of nociceptive information
are encoded and altered at the level of cells and circuits
within neocortical networks during pain chronicity.
These studies have also addressed cause–effect relation-
ships in animal models, which form the main focus of
this Review.
At the outset, it is important to acknowledge and
highlight a difficult conundrum in this field. Neocortical
domains are not only recruited during pain perception
but also continuously drive a plethora of brain functions,
including cognition, decision-​making, memory, emotion
and homeostatic control. A clear outcome of a large body
of evidence is that there is no single neocortical domain
that is ‘specific’ for pain, unlike its counterparts in the
peripheral nervous system, spinal superficial dorsal horn
and brainstem, where ‘nociception-​specific’ functional
entities have been identified2,3,8,9. However, to the suf-
ferer, pain constitutes a unique percept and experience
that cannot be confounded with another sensation or
emotion, and there is unequivocal evidence that the neo-
cortex plays a critical role in this experience. How spec-
ificity for pain perception is created, therefore, remains
one of the grand challenges in biology and medicine.

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Box 1 | Functional specificity in pain
In terms of regionally specific contributions to pain, recent studies both support and
challenge the notion of pain specificity in designated cortical domains, such as the
dorsal anterior cingulate cortex and the insular cortex158–161. New evidence has also
challenged the dogma of broad segregation of cortical areas into purely sensory
discriminative versus emotional, and suggests the existence of functional subdivisions
within each of the cortices. At the next level of resolution, functional specificity may
be imparted by distinct pathways and circuits. In support of this, recent connectivity
analyses and optogenetic studies demonstrate that selective corticofugal pathways,
such as prefrontal projections to the nucleus accumbens or posterior insula projections
to the rostroventral medulla enhance pain, while others, such as prefrontal cortical
projections to the periaqueductal grey, attenuate pain29,42,44,99. At the next level of
fine-​grained cellular maps, specificity of information coding may be conferred by specific
neocortical neuronal ensembles (that is, populations of neurons with coordinated
activity that computationally encode specific functions)162. Specific subsets of neurons
that co-​fire in response to noxious stimuli, such as those recently described in the
amygdala117, may selectively encode pain perception, and their fluctuations upon
intrinsic and extrinsic modulatory influences may account for abnormal variations in
pain perception in chronic pain states. Finally, looping back to the notion that pain is
a network-​driven process, oscillatory brain rhythms, such as alpha, theta and gamma
frequency rhythms163,164, can provide a mechanistic basis for distinguishing noxious
from innocuous intensity stimulation and explain abnormal fluctuations of neural
activities in chronic pain states. Moreover, by serving as a mechanism for short-​range
and long-​range communication between distributed neuronal ensembles and circuits,
they may enable temporal coordination of information across distant, spatially separated
networks and thus help functionally integrate sensory and emotional–motivational
aspects into a comprehensive pain percept.
In this Review, we propose that functional specificity
for pain outcomes in neocortical networks and their cor-
ticofugal projection targets may come about at least at four
distinct, but inter-​related, levels: (1) dynamic activity states
in neocortical networks, (2) regional, functionally distinct
subdomains, (3) specific circuit connections that deline-
ate pain from other functions, and (4) cellular ensembles
of co-​active, functionally homogenous populations of
neurons (see Box 1). In support, we highlight evidence
from recent animal and human work in the context of key
pain-​related neocortical areas, namely, the prefrontal cor-
tex (PFC), midcingulate cortex (MCC), anterior cingulate
cortex (ACC), anterior insula (AI), posterior insula (PI),
primary somatosensory cortex (S1) and secondary soma-
tosensory cortex (S2). Several of these regions are also
implicated in anxiodepressive disorders that frequently
accompany chronic pain as co-​morbidities (Box 2).
Functional contributions of distinct cortical
domains in pain
The PFC, ACC, insula, S1 and S2 neocortices are part
of the ‘neurologic pain signature’, a defined brain activity
pattern that is derived from a multivariate pattern analysis
of functional MRI data combined with machine learning,
Multivariate pattern which can be used to predict acute pain associated with
analysis activation of nociceptors by noxious stimuli2. Moreover,
A set of tools that can analyse a similar approach was applied on large imaging data
and identify neural responses
sets to predict pain beyond nociceptive input to yield
in the brain as spatially
distributed patterns of activity. stimulus intensity-​independent pain signature 1, which
includes the lateral PFC as a neocortical component
Machine learning in addition to the parahippocampal cortices and the
The use of computer nucleus accumbens (NAc)10. Similarly, rodent imaging
algorithms to learn, analyse,
identify and predict patterns
studies also reveal the S1 and the insular and cingu­
from data sets with minimal late cortices to be the neocortical domains that are
human supervision. consistently activated during acute pain11.
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Prefrontal cortex
In humans and non-​human primates, the PFC includes
the medial PFC (mPFC), ventrolateral PFC, dorsolat-
eral PFC (dlPFC), ACC and orbitofrontal cortex (OFC),
encompassing the anatomically defined Brodmann areas
8–14, 24, 25, 32 and 44–47 (ref.12). Anatomical and phys-
iological comparisons suggest that the rodent mPFC can
be subdivided into the ACC, prelimbic (PL) cortex and
infralimbic (IL) cortex, which are homologues compa-
rable to areas 24, 32 and 25, respectively, of primates.
However, thus far, difficulties in reconciling data from
human, primate and rodent PFC pain studies have risen
mainly due to the use of ambiguous or hybrid nomen-
clatures (for example, ‘prelimbic mPFC’ and ‘ventral
mPFC’) and the use of different brain schemes and
atlases13, leading to confusion among researchers regard-
ing the actual PFC areas being investigated (see Table 1).
Here we attempt to describe only recent studies where
detailed regional information is available so as to get a
clearer picture of the roles and circuitries of the specific
PFC subdomains in pain.
The PFC in pain. Neuroimaging studies often implicate
PFC activation in response to acute nociceptive stim-
uli (lasting milliseconds to seconds) in healthy people9.
Under longer-​lasting pain conditions, a prominent
role for altered PFC functional connectivity and differ-
ential activity in pain modulation have also been well
documented9,14,15. Here, analysis of neural oscillatory
responses to tonic experimental noxious stimuli (lasting
minutes) frequently reveals enhanced power of gamma
oscillations and suppression of alpha and beta oscilla-
tions in prefrontal areas that are closely associated with
stimulus and pain intensities16–18. Similarly, increases in
the resting-​state gamma activity and power in the PFC
have also been observed during chronic pain conditions,
reflecting a shift towards an emphasis and recruitment
of emotional–motivational processes in the PFC during
the encoding of chronic ongoing pain17,19–22.
In animal models, neuronal oscillations in the
PFC in pain states have not been well studied so far.
Furthermore, depending on the areas of the PFC under
investigation, conclusions regarding the state of ‘PFC’
or ‘mPFC’ activity in pathological pain can differ sig-
nificantly, and different maladaptive changes in specific
PFC domains are reported in different types of chronic
pain. In the following sections, we discuss the roles
of specific PFC subdomains and summarize key PFC
pathways linked to alterations in pain.
Regional and laminar contributions. Although neu-
rons responsive to both innocuous and noxious stimuli
have been recorded in both the PL cortex and the IL
cortex of healthy rodents23,24, structural and functional
data support a more prominent role for the PL cortex
in pain processing (Fig. 1). For instance, bilateral lesions
of the PL cortex, but not the IL cortex, prevented the
development of inflammatory-​induced hyperalgesia and
pain aversion25,26. Similarly, altered intrinsic excitability
of PL neurons, but not IL neurons, is observed after
nerve injury27. Furthermore, using markers of neuronal
activation and sensitization (for example, CREB/p38
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phosphorylation and FOS), others have also reported
enhanced PL cortex activation during acute and persis-
tent pain states28,29. Although the rodent PL cortex is the
most studied PFC region in pain, its role remains highly
unclear given that both activation and deactivation have
been reported in diverse models and studies in the con-
text of pain. While PL cortex activation is suggested to
be required for inflammatory pain25,26, the predominant
view points to a diminished activity of the mPFC during
chronic neuropathic pain27,30–32.
Differential dysregulation of the various PL cortical
layers is reported in chronic pain models. For example,
after a peripheral nerve injury, structural losses in layer 5
PL pyramidal neurons32 and reduced local excitatory
inputs27 likely contribute to the decreased excitability of
layer 5 pyramidal neurons that is often seen in chronic
pain models27,30–32 (Fig. 1). Such reduced excitability has
also been suggested to be partly mediated by enhanced
feedforward inhibition from fast-​spiking parvalbu-
min (PV)-​type interneurons31, but not somatostatin
(SOM)-​containing GABAergic interneurons27, which are
driven by increased glutamatergic inputs from the baso-
lateral amygdala (BLA) to these PV-​type interneurons
after nerve injury31,33. Activation of mGluR1-​type glu-
tamate receptors (presumably from BLA afferents), but
not mGluR5-​type receptors, presynaptic to GABAergic
interneurons is critically involved in driving this mPFC
inhibition24. Interestingly, it was recently demonstrated
such nerve injury-​induced increases in PV-​type neuronal
excitability occur only in male mice34, suggesting that
sex-​specific GABAergic mechanisms underlie chronic
pain. Furthermore, impairments in endocannabinoid,
cholinergic, catecholaminergic, opioidergic and dopamin-
ergic signalling also contribute to the altered prefrontal
excitability reported during sustained pain5,35,36.
Excitability of layer 2/3 PL neurons is significantly
attenuated during inflammatory pain25 but has also
been reported to be unaffected37 or even increased30,38
Box 2 | Neural circuits of pain co-​morbidities
Chronic pain is a strong trigger of co-​morbid disorders of negative emotions such
as persistent stress, depression, anxiety, addiction vulnerability and memory deficits.
In turn, these affective conditions can aggravate pain duration and sensitivity,
making it a relentless cycle that is a challenge to treat effectively (see reviews118,165,166).
Unsurprisingly, brain regions such as the prefrontal cortex, anterior cingulate cortex,
amygdala, insula and nucleus accumbens that are commonly implicated in affective
and cognitive disorders are also reported to be involved in regulation of negative affect
in patients with pain.
Specific neural circuits underpinning core co-​morbid traits of chronic pain are only
just beginning to be explored in animal models. These studies have revealed novel
functional contributions of various subcortical circuits involving the dorsal raphe
nucleus, lateral habenula, amygdala and parabrachial nucleus in the regulation of
negative emotions such as anxiety and depression induced by chronic pain134,167,168.
In terms of neocortical contributions, co-​morbid anxiodepressive behaviours in animal
models of chronic pain were reported to be driven by persistent hyperactivity of the
anterior cingulate cortex72, where lesions of the anterior cingulate cortex, but not
the posterior insula, sufficiently prevented the development of anxiodepressive
behaviours in chronic pain models71. More recently, in a persistent inflammatory pain
model, enhanced activity of the excitatory projections from the primary somatosensory
cortex to GABAergic neurons residing in the caudal dorsolateral striatum was also
found to modulate co-​morbid anxiety97, highlighting that the primary somatosensory
cortex, in addition to its predominant role in somatosensory processing, can also
contribute to emotional states in pain.
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in neuropathic pain models. Increases in noradren-
ergic innervation38 as well as dendritic complexity
and the lengths of these layer 2/3 neurons have been
described30,37, suggesting a reorganization of intracortical
circuits contributing to neuropathic pain. Such morpho-
logical changes are also accompanied by dysregulated
NMDA receptor-​mediated currents, α2-​adrenoceptor
activity and impaired hyperpolarization-​a ctivated
cyclic nucleotide-​gated (HCN) channels, all of which
have been correlated with nociceptive hypersensitivity
in vivo38,39 (Fig. 1).
Thus far, altered IL cortical activity has been detec­
ted during inflammatory pain, where it has been linked
to an impaired interaction between presynaptic CB1-​
type cannabinoid receptors and postsynaptic mGluR5
receptors 24. Under neuropathic conditions, the IL
cortex does not appear to contribute to chronic pain
signalling27,30. Rather, chronic pain-​related cognitive
impairments have recently been linked to morpholog-
ical changes of PV-​type interneurons in layers 5 and 6
of the IL cortex40.
PFC–NAc pathway. The PFC projects to the NAc, one of
the major nodes in the reward circuitry, and in human
imaging studies, an initial enhanced mPFC–NAc func-
tional connectivity correlated with and predicted the
persistence of pain in patients with chronic back pain15,41,
suggesting a facilitatory role for prefrontal–striatal con-
nectivity in pain. However, in animal models of acute
and chronic pain, selective optogenetic activation of the
PL output to the core region of the NAc significantly
inhibited pain-​related behaviours42,43, while optogenetic
suppression of the same pathway enhanced nociceptive
sensitivity in both uninjured and neuropathic animals44
(Fig. 1). Thus, additional translational studies are needed
to resolve the role of PFC–NAc connectivity in pain. The
IL cortex–NAc projection has not been examined in
the context of pain.
PFC–PAG pathway. PFC projections to the periaque-
ductal grey (PAG), a key node within the descending
pain modulation network, have been extensively char-
acterized in several mammalian species12. These studies
are further supported by functional MRI and diffusion
tensor imaging studies in humans, confirming the exist-
ence of a PFC–PAG circuitry that underlies top-​down
influences on spinal nociceptive processing9,45. The PAG
projects to downstream targets that include serotonin-
ergic neurons in the raphe nuclei of the rostroventral
medulla (RVM), which project to the dorsal horn of
the spinal cord, where peripheral noxious inputs are
received and processed.
Within the rodent mPFC, a major subpopulation of
layer 5 neurons in both the PL region and the IL region
projects to the PAG27,46. In mouse models of chronic con-
striction nerve injury, the intrinsic excitability of PL–PAG
neurons, but not of IL–PAG neurons, is markedly atten-
uated bilaterally27, suggesting that reduced activity of
the PL–PAG pathway contributes to the persistence
of neuropathic pain (Fig. 1). Recently, with use of trans-
synaptic tracing with optogenetic, chemogenetic and
lesioning tools, it was further demonstrated that specific
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Table 1 | Annotations used to describe frontal regions in rodent and human brain been further subdivided into the pregenual (rostral)
versus subgenual (ventral) regions50,51. Mounting evidence
Species Common terms used Frontal subregions Common from numerous human and rodent studies supports a
to describe frontal frequently studied in pain anatomical
subregions involved annotations dual role for the ACC in processing both the sensory and
in pain the emotional aspects of pain29,52–55. Hyperactivation of the
ACC is consistently reported in patients with chronic
Rodent mPFC, dmPFC, vmPFC, ACC, also referred to as mPFC Cg1, Cg2, area
ACC/ACA, rACC, and rACC 24a, area 24b pain and animal models with heightened pain percep-
prelimbic mPFC, tion, and has also been associated with psychological or
Prelimbic, also referred to PL, PrL, Cg3,
prelimbic PFC, PL/PrL,
as mPFC, dmPFC, prelimbic area 32 negative emotional factors in pain, including aversion,
IL/ILA, medial FC, unpleasantness, social rejection and distress1,55. However,
rostral MC, caudal mPFC, dorsal cingulate cortex
MC, medial OC, ORB, and rostral MC it remains unclear whether distinct ACC circuits modu-
MO, AI Infralimbic, also referred to as IL, ILA, area 25 late behavioural responses to noxious stimuli and affec-
mPFC, vmPFC, caudal cingulate tive evaluation and whether they undergo independent
cortex and rostral MC maladaptive changes during pain chronicity.
Human dlPFC, mPFC, dmPFC, dlPFC Brodmann areas
vmPFC, vlPFC, 8, 9 and 46 Dorsal ACC. The human dorsal (dACC), also referred
amPFC, anterior PFC, to as the anterior MCC, is implicated in diverse neuro-
frontopolar PFC, rostral ACC Brodmann areas
PFC, ACC, dACC, 24, 25, 32 and 33 logical processes, including empathy, action evaluation
pregenual (rostral) and negative pain affect, wherein activation of the dACC
ACC, subgenual by noxious stimuli has been consistently reported in the
(ventral) ACC, OFC imaging literature51,56,57. Lesioning of the dACC has also
ACA, anterior cingulate area; ACC, anterior cingulate cortex; AI, agranular insular area; been successful for the treatment of chronic refractory
amPFC, anteromedial prefrontal cortex; Cg, cingulate area; dACC, dorsal anterior cingulate pain and affective disorders58. Interestingly, a recent
cortex; dlPFC, dorsolateral prefrontal cortex; dmPFC, dorsomedial prefrontal cortex;
FC, frontal cortex; IL, infralimbic cortex; ILA, infralimbic area; MC, medial cortex; MO, secondary report demonstrated that positive connectivity between
motor area; mPFC, medial prefrontal cortex; OC, orbital cortex; OFC, orbitofrontal cortex; the dACC and the primary motor cortex (M1) could be a
ORB, orbital area; PFC, prefrontal cortex; PL and PrL, prelimbic cortex; rACC, rostral anterior
cingulate cortex; vlPFC, ventrolateral prefrontal cortex; vmPFC, ventromedial prefrontal cortex.
useful predictor of chronic pain development in survivors
of motor vehicle trauma injuries59.

deactivation of the pathway from the PL cortex to the
ventrolateral PAG, via enhanced GABAergic tone in
the PL cortex, functionally contributes to hypersensitiv-
ity in mice with neuropathic pain47. Such an observa-
tion is supported by a large number of human imaging
studies which imply that a deactivation of the mPFC in
patients with neuropathic pain is associated with a loss of
descending inhibition9. The role of the IL–PAG circuit in
chronic pain pathology remains to be clarified.
PFC–amygdala pathway. The mPFC is reciprocally con-
nected with the amygdala. Increased intracorticolimbic
white matter and functional connectivity within the
mPFC–amygdala–hippocampus circuitry has been
identified as a risk factor for persistence of back pain48.
In rodents, principal cells in both the PL cortex and the
IL cortex project to neurons in the BLA and the inter­
calated cell mass of the amygdala; this is critical for corti­
cally driven feedforward inhibition of the amygdala, and
its impairment leading to hyperactivity of the BLA has
been linked to nociceptive hypersensitivity in chronic
pain46,49 (Fig. 1). Recently, specific dysfunction in the
IL–amygdala pathway has also been reported in chronic
pain models 49, in line with structural tracing data
showing that the BLA is innervated by neurons present
in the superficial and deep layers of the IL cortex46.
Anterior cingulate cortex
Although the ACC domain of the cingulate is classically
considered to be part of the PFC, we discuss the roles of
the ACC in pain in this section to enable a better compar-
ison with the other cingulate domain, namely, the MCC,
later. The human ACC is often subdivided into dorsal ver-
sus ventral regions, wherein the ventral portion has also
Rostral and ventral ACC. The perigenual ACC, also
referred to as the rostral ACC (rACC), has extensive
connections to other cingulate areas and the PAG50.
Disrupted rACC connectivity with brain regions of
the default mode network has been found in patients
with chronic back pain19, while enhanced connecti­
vity with the salience and sensorimotor networks was
recently demonstrated in patients with migraine and
visceral pain60,61, highlighting atypical rACC function
in aberrant pain processing.
Imaging data suggest a sex-​dependent role of the
ventral ACC, also known as the subgenual ACC,
in pain modulation, with female patients with chronic
pain displaying greater subgenual ACC connectivity to
areas of the default mode and sensorimotor networks
than male patients with chronic pain, suggesting that
subgenual ACC circuitry in women is associated with
a stronger engagement of descending modulatory sys-
tems that likely contribute to better pain adaptation
and habituation to repeated noxious stimuli62,63.
Rodent ACC. Extensive rodent studies have provided
detailed insights into ACC mechanisms in pain55,64.
Several types of ACC pyramidal populations have
been identified on the basis of their firing properties in
response to noxious and non-noxious inputs 65,66.
In chronic pain models, layer 2/3 neurons undergo
structural changes, with increased dendritic complexity
and spine densities, and become hyperexcitable37,67,
similar to observations in layer 2/3 neurons of the PL
cortex. However, unlike in the PL cortex, intrinsic excit-
ability of layer 5 ACC pyramidal neurons is potentiated
in chronic pain, while interneurons appear to remain
unaffected after nerve injury52,66.

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Seminal work by Zhuo and colleagues has high-
lighted the role of synaptic plasticity in the ACC in both
acute and chronic pain, particularly in various forms of
long-​term potentiation triggered by activation of NMDA
receptors, kainate receptors, adenylyl cyclase and diverse
signalling kinases in the ACC, all of which were linked
to neuronal hyperexcitability55,68. Recently, studies also
reported altered activity of HCN channels in pyramidal
neurons, leading to impaired Ih currents and significant
loss of reciprocal synaptic connections between inhib-
itory and pyramidal layer 5 populations, both of which
are suggested to cause disinhibition of the local ACC
microcircuitry in chronic pain66,69. Optogenetic experi-
ments indicate a role for the PV-​type, but not SOM-​type,
interneurons in the regulation of the ACC excitability
in nociception70. However, other studies have demon-
strated that neuropathy-​induced hypersensitivity is
not consistently affected by lesions or inhibition of the
ACC71,72, suggesting that other brain areas may play a
more critical role in the sensory processing during pain
states (such as the MCC and the insula; see later).
ACC hyperexcitability has also been linked to
pain-​associated negative affect in various rodent models
of chronic pain, commonly reflected by a reduced
place escape avoidance or conditioned place aversion
induced by a noxious stimulus. Lesion or suppression
of neuropathy-​induced or inflammatory pain-​induced
ACC hyperactivity reduces pain aversion72–74, while elec-
trical or optogenetic stimulation of the ACC in naive
animals sufficiently induces aversive behaviours29,75.

a Structural Functional Mechanisms

1
↑ Basal spine density ↑ Excitability (neuropathic) Alterations in HCN channels,
2/3 ↑ Noradrenergic innervation ↑ Excitability (inflammatory) α2-receptor kinetics and
Cortical layers

↓ Excitatory inputs ↓ Inhibition (neuropathic) NMDA-mediated currents

↓ Apical spine complexity ↓ Excitability (neuropathic) Alterations in M1 and CB1

5 ↓ Excitatory inputs ↓ Excitability (inflammatory) receptor expression
↑ Inhibition (neuropathic)
6

CeA LC

Layer 5 Layer 2/3

NAc
ITC

BLA PL vIPAG
cortex

Sensory pathways Excitatory pyramidal neuron

Increased activity in hypersensitivity Excitatory neuron
Decreased activity in hypersensitivity GABAergic neuron
Affective pathways PV-type GABAergic neuron
Decreased activity with more negative pain affect Noradrenergic neuron

Fig. 1 | The PL cortex. a | Structural and functional plasticity reported in layer 2/3 and layer 5 neurons of the prelimbic
(PL) cortex. b | Major input and output pathways of the PL cortex known to modulate sensory states (in green) and negative
affective states (in blue) in acute and chronic pain. Parvalbumin (PV)-​type GABAergic neurons in layer 5 provide feedforward
inhibition leading to PL cortex deactivation and subsequently mechanical hypersensitivity during chronic pain. Modulation
of PL PV-​type GABAergic neurons by basolateral amygdala (BLA) efferents in pain is also shown. Increases (solid line)
and decreases (dotted line) in pathway activity leading to nociceptive hypersensitivity and pain aversion are indicated.
Light-​grey dashed lines indicate the delineation of cortical layers. CeA, central amygdala; HCN channels, hyperpolarization-​
activated cyclic nucleotide-​gated channels; ITC, intercalated cell mass of the amygdala; LC, locus coeruleus; M1, primary
motor cortex; NAc, nucleus accumbens; vlPAG, ventrolateral periaqueductal grey.

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1 ACC MCC PI 1 S1 S2
Cg1
2/3 2/3

5 Cg2 5

6 6

NAc ZI Striatum
Co-morbid
pain

BLA
PAG
Parafascicular
nucleus
MD VTA
RVM

Spinal cord

Sensory pathways Excitatory pyramidal neuron

Increased activity in hypersensitivity Excitatory neuron
Decreased activity in hypersensitivity GABAergic neuron
Affective pathways Dopaminergic neuron
Increased activity with more negative pain affect Serotonergic neuron
Decreased activity with more negative pain affect

Fig. 2 | Overview of major neocortical circuits and their known efferent pathways that modulate nociception
(in black) and negative affective states (in red) in acute and chronic pain. Top-​down circuits with which excitatory
neurons in the deep layers of the anterior cingulate cortex (ACC), posterior insula (PI) and primary somatosensory cortex
(S1) send projections directly and indirectly to the dorsal horn of the spinal cord to modulate descending modulation
of sensory inputs, all of which can contribute to central sensitization under physiological and pathological conditions,
leading to heightened pain responses. Increases (solid line) and decreases (dotted line) in pathway activity leading to
nociceptive hypersensitivity and pain aversion are indicated. BLA, basolateral amygdala; Cg1, cingulate area 1; Cg2,
cingulate area 2; MCC, midcingulate cortex; MD, mediodorsal thalamus; NAc, nucleus accumbens; PAG, periaqueductal
grey; RVM, rostroventral medulla; S2, secondary somatosensory cortex; VTA, ventral tegmental area; ZI, zona incerta.

ACC–NAc and ACC–VTA pathways. Despite strong evi-
dence implicating its role in pain-​related aversion, the
underlying ACC microcircuitry has not been as exten-
sively studied. Recent data suggest that the ACC regu-
lates pain-​related aversion via distinct subdomains and
pathways differentially from behavioural hypersensitivity.
Optogenetic studies29 indicate a dichotomy between the
rostral division versus the middle division of the cingulate
cortex in processing pain affect, with the rACC having a
key role in generating aversion. In neuropathic models,
viral tracing and chemogenetic tools confirm the role of
ACC projections to mesolimbic dopaminergic regions,
namely, the NAc and ventral tegmental area (VTA), in
pain aversion but not in mechanical or thermal hyper-
sensitivity induced by nerve injury76 (Fig. 2). It remains to
be determined whether this ACC–NAc pathway is related
to the finding that direct medial thalamus inputs to ACC
subcortically projecting cells modulate pain aversion66.
These observations are interesting, since an earlier study
revealed an opposing role of the PL–NAc pathway (Fig. 1),
that is, inhibition of pain-​related aversion42, highlighting
again that specific prefrontal domains carry out highly
different roles via specific projections.
ACC–spinal cord pathway. Recently, spinally project-
ing neurons residing in layer 5 of the ACC in mice were
linked to pain modulation (Fig. 2). Electrical and selec-
tive optogenetic stimulation of these ACC spinal cord-​
projecting neurons was found to facilitate spinal sensory
excitation and mechanical hypersensitivity77. Conversely,
inhibiting the same pathway alleviated neuropathy-​
induced hypersensitivity, providing evidence for a direct
top-​down descending facilitatory role of the ACC in
chronic pain that is independent of descending pathways
that originate in the brainstem77.
The MCC in pain
Since the clarification of the MCC as a cytoarchitec-
turally and functionally distinct region of the cingulate
cortex78, it has been implicated in numerous brain pro-
cesses, including pain anticipation and sensitivity56,79.
In rodents, as discussed earlier, major efforts have been

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devoted to investigating the role of the ACC and its
associated circuits in pain-​related processes. How­
ever, although the MCC receives a similarly wide array
of inputs from cortical and subcortical regions as the
ACC 80, the identification of specific MCC circuits
modulating pain has remained sparse.
MCC–PI pathway. Recently, a study highlighted the
involvement of the novel pathway from the MCC to the PI
that contributes to acute and persistent inflammatory
pain, but not to chronic neuropathic pain, and evokes
nociceptive hypersensitivity in the absence of periph-
eral injury by PI-​dependent activation of descending
serotonergic facilitation, while MCC–NAc projections
did not modulate nociception29 (Fig. 2). Moreover, opto-
genetic activation experiments indicated that the MCC
functionally modulates pain independently of affective
or emotional aspects, and implicated the rACC in these
aspects instead29.
MCC–zona incerta pathway. Recently, Hu and col-
leagues further discovered that selective MCC excitatory
projections (dorsal cingulate area 1 (Cg1) versus ventral
cingulate area 2 (Cg2)) to the GABAergic population
residing in the zona incerta (ZI), a subthalamic region,
undergo differential activity during chronic neuropathic
pain81, wherein activity of the Cg2–ZI pathway was
dampened (Fig. 2). Interestingly, restoring activity of this
pathway in particular, but not of the Cg1–ZI pathway or
the Cg2–PAG pathway, significantly reduced nocicep-
tive hypersensitivity, suggesting that a dysfunction of the
endogenous inhibitory system comprising the MCC Cg2
and ZI is associated with neuropathic pain. Collectively,
these studies suggest that distinct MCC subdomains are
operational and perform different roles in the process-
ing of acute and chronic pain29,81, and suggest that the
MCC serves as an origin of pathways mediating inhi-
bition (MCC Cg2–ZI) as well as descending facilitation
(MCC–PI–RVM) of nociception (Fig. 2).
Primary somatosensory cortex
The S1 is one of the most studied cortical areas for pain
perception, and has commonly been thought to repre-
sent the sensory-​discriminative component of pain. In
recent years, however, it has been revealed that this is
an overgeneralization and that a number of functions,
including emotions, can also influence pain processing
in the S1 (refs82,83).
Recent in vivo calcium imaging experiments in mice
revealed complex processing of incoming somatosen-
sory information in layer 2/3 neurons of the S1, where
distinct neurons have selective tuning properties that
encode multiple features, such as texture, dynamics
and intensity of cutaneous stimuli, suggesting that tac-
tile information is well discriminated at the single-​cell
level in the S1 (ref.82). In parallel, imaging and microe-
lectrode recordings in the primate indicate that there is
a functional and spatial segregation between groups of
neurons processing innocuous tactile versus nociceptive
heat and cold information within the S1 (ref.84), raising
the possibility of modality-​specific thalamic inputs to
S1 subregions.
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Activity rhythms in the S1. Within the S1 region,
human electrophysiological studies frequently demon-
strate a strong enhancement of gamma-​band power
that is driven in response to brief nociceptive stimuli
and associated with the subjective pain intensity18,85–87.
Concurrently, transient decreases in low-​f requency
(below 30 Hz) oscillatory powers in the sensorimotor
regions are often observed, which have been proposed
to reflect sensory gating mechanisms and to facilitate
motor reactions to the painful threat17,88,89.
Mechanistic insights into the functional roles of
these S1 oscillations in pain were recently explored in
animal models. These studies revealed that S1 gamma
rhythms were evoked in response to brief noxious
somatosensory stimuli but not in response to other
sensory stimulation (for example, visual), motor
activity or salience83,90. Such S1 gamma rhythms were
linked to activity of interneurons83,91, whereby opto-
genetic gamma entrainment of S1 PV-​type interneu-
rons in particular led to nociceptive hypersensitivity
via activation of descending serotonergic pathways in
the brainstem, providing the first causal evidence
in vivo for a cell-​type-​specific and pathway-specific
mechanism for S1 gamma rhythms in acute pain83.
Interestingly, S1 gamma entrainment also elicited
pain aversion and negative affect, likely via facilitating
information flow to the rACC, a cortical area critically
implicated in pain affect29. Under persistent pain con-
ditions, enhanced spontaneous gamma activity in the
S1 is also observed, with increases in gamma power
positively correlating with the severity of pain83,92, high-
lighting the significance of S1 gamma activity not only
in physiological pain but also extending to pathological
pain conditions.
Whether and how the S1 contributes to chronic
pain is debated. Several studies have reported a lack of
phenotypic alterations in nociception and pain upon
lesions or optogenetic silencing of the S1 in rodents29,93.
Conversely, persistent hyperactivity of S1 neurons
has been reported in models of neuropathic pain94,95,
which has been attributed to reduced activity of local
SOM-​expressing GABAergic interneurons95, unlike the
key role ascribed to PV interneurons in local circuit
dysfunction in the PFC31.
Finally, peripheral nerve injury triggers maladaptive
structural plasticity and cortical reorganization in the
S1 in chronic pain states of different causes, including
phantom limb pain4,96. Causal relationships between cor-
tical structural remodelling and pain chronicity have not
yet been established, and it remains to be determined
whether these constitute a cause or a consequence of
chronic pain4. In the following sections, we review effer-
ent pathways of the S1 that have been implicated in pain
modulation.
S1‒dorsolateral striatum pathway. Recently, viral tract
tracing identified a novel pathway from layer 5 S1 gluta­
matergic neurons projecting to GABAergic neurons
in the caudal dorsolateral striatum (Fig. 2). Selective
chemogenetic and optogenetic experiments suggest
that this S1–striatum pathway functionally contributes
to inflammatory mechanical hypersensitivity97.

S1‒ACC pathway. A recent study using a combination
of tract tracing, optogenetics, in vivo electrophysiology
and machine learning analysis reported the involvement
of a corticocortical S1–ACC pathway in nociception98.
The study authors identified an ACC neuronal popu-
lation receiving direct inputs from the S1, which is pre­
ferentially responsive to noxious stimuli, show enhanced
responsivity during inflammatory pain and are function-
ally linked to sensory and pain-​related aversive behav-
iours in a chronic pain model98 (Fig. 2). This suggests that
direct relay of nociceptive information between these
neocortical centres serves to integrate sensory and affec-
tive components of pain. Indeed, previous studies have
shown that electrical responses of the ACC correlated
with S1 neuronal activity during peripheral stimulation94
and that optogenetic manipulation of S1 activity can also
lead to enhanced ACC activation83.
S1–spinal cord pathway. Labelling studies in mice have
identified corticospinal projections from the S1 hind-
limb area to laminae III–V of the spinal cord, suggesting
a role for these projections in tactile sensory processing99.
These corticospinal projections likely co-​terminate with
low-​threshold mechanosensory afferents in the spinal
cord100, since selective ablation of these neurons reduced
responses to innocuous tactile but not to nociceptive
stimuli. Importantly, ablation or functional suppression
of this pathway attenuated evoked mechanical hyper-
sensitivity after nerve injury, highlighting that these
S1 corticospinal projections contribute to the generation
of pathological nociceptive hypersensitivity99 (Fig. 2).
Secondary somatosensory cortex
Intracerebral stimulation of the S2 area in patients
undergoing brain surgery for various reasons elicits
somatosensory responses and painful sensations, but
not non-​somatosensory responses such as auditory, ves-
tibular or olfactogustatory sensations101. Somatosensory
responses in the S2 area correlate with the intensity of
stimuli, contributing to the encoding and discrimination
of somatosensory stimulus intensities102,103.
Surprisingly, in animal models, the role of the S2 in
pain has only recently begun to attract interest. Recent
imaging data from awake neuropathic mice indicated
enhanced neural activity in the S2 region of rodents with
nerve injury104. Recently, neurons in the parafascicular
thalamic nucleus were reported to relay to the S2, and
the decrease in their excitatory tone was observed to
modulate depression-​associated co-​morbid pain, but not
inflammatory or neuropathic pain105. It remains to be
further investigated whether and how specific S2 efferent
pathways influence pain processing.
Insular pathways in pain
The insular cortex is involved in an enormous array
of functions, including homeostatic and interoceptive
processes, motivation, addiction, sensorimotor integra-
tion and processing of emotions such as pain, anxiety
and empathy106,107, and is well connected with numer-
ous cortical and subcortical structures108. Acute painful
responses arising from selective neural stimulation of
the insula in both animals and humans are consistently
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shown18,29,109, while robust phase-​locked gamma-​band
oscillations in response to acute and sustained ther-
monociceptive but not non-​nociceptive stimuli can be
recorded in both the AI and the PI110,111. Intracranial and
imaging recordings suggest that information from noci-
ceptive inputs is directed from the PI to the AI, with the
posterior and mid-​regions of the PI strongly connected to
sensorimotor cortices and associated with encoding for
sensory aspects such as intensity, somatotopy and modal-
ities, while the AI is strongly connected to PFC regions
and functionally integrates affective processes related to
the painful sensation112, although a recent study has sug-
gested that the AI is also capable of rapidly conveying
and integrating limbic and sensory inputs in parallel113.
Abnormal intrinsic insular cortical reorganization has
been associated with prolonged pain in patients, with
decreased grey matter volume in various insula sub-
regions being detected as well as enhanced functional
connectivity between the PI and regions such as the
cerebellum and the hippocampus being observed114.
Animal studies also support a key role for the insula
in both nociceptive and affect modulation29,108. Indeed,
there is overwhelming evidence for the critical contri-
butions of injury-​triggered long-​term potentiation and
plasticity in the insula in pathological pain115,116. Novel
work with viral tracing and pharmacological inhibition
indicates that acute peripheral hypersensitivity induced
by activation of the MCC–PI pathway is mediated by
gluta­matergic projections from the PI to serotonergic
neurons in the raphe nuclei and subsequently to the spinal
facilitation via descending facilitatory mechanisms29
(Fig. 2). Using fibre photometry and calcium imaging
recordings, an elegant study demonstrated that high
levels of neural activity in the PI correspond to the
animal’s state of anxiety and that a subset of these insu-
lar neurons are also activated upon a painful tail shock
stimulus108. Furthermore, optogenetic stimulation of the
PI–central amygdala (CeA) pathway, but not the PI–NAc
projections, strongly modulated aversive and anxiety-​like
behaviours108, suggesting that aversive inputs that induce
fear and anxiety arrive at the CeA via the PI. The CeA
also receives direct inputs conveying information per-
taining to aversive stimuli from the parabrachial nucleus5
as well as from the BLA, and recent in vivo calcium
imaging demonstrated that a distinct neuronal ensem-
ble in the BLA encodes the aversive state during noxious
stimulations117. Hence, it would seem that several parallel
pathways, some involving the neocortex and others of
subcortical origin, encode aversion and are related to
fear induction following pain perception. It remains to be
clarified as to how either of these pathways contributes
to the persisting hyperanxious behaviours that typically
develop in models of chronic pain118.
Cortical circuits as pharmacological targets
Opioidergic drugs
A well-​described mechanism of opioid analgesia is
attributed to descending inhibition of spinal nocice-
ption via actions at diverse stations along descending
pathways, including the PAG, the RVM and other brain-
stem nuclei, and via direct actions on primary nocic-
eptors and the spinal cord119. Cortical pathways are a
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Mindfulness/
OFC self-regulation Opioids

Placebo
Placebo Ketamine CPM rTMS/tDCS
rTMS tACS

vlPFC dlPFC S1–S2 Posterior

rACC sensorimotor insula M1
mPFC

Opioids Cannabinoids Cannabinoids

(pain affect)

Opioids Placebo
Placebo
(sensory)

Opioids
+ (reward) CPM
Amygdala PAG Thalamus
NAc Opioids

CPM
RVM
Opioids

Pharmacological therapy SC Opioids

Non-pharmacological therapy

Fig. 3 | Overview of neocortical structures and their known efferent pathways that serve as targets of
pharmacological analgesics as well as neurostimulation and neuromodulation/cognitive therapies in chronic pain.
Black arrows point to regions and pathways targeted by each therapy. Both neocortical processing and efferent pathways
(represented by grey arrows) to brain centres mediating reward learning (nucleus accumbens (NAc)) and conditioned
learning (amygdala) and descending modulation of nociception (periaqueductal grey (PAG) and rostroventral medulla
(RVM)) are affected. Commonalities as well as differences are found with respect to neocortical mechanisms underlying
diverse therapies, providing a neurobiological basis for an additive or synergistic potential with combination therapies.
Anatomical pathways are depicted by grey arrows. Each mode of therapy is depicted in differently coloured text and
with arrows to the brain regions involved. CPM, conditioned pain modulation; dlPFC, dorsolateral prefrontal cortex;
M1, primary motor cortex; mPFC, medial prefrontal cortex; OFC, orbitofrontal cortex; rACC, rostral anterior cingulate
cortex; rTMS, repetitive transcranial magnetic stimulation; S1, primary secondary somatosensory cortex; S2, secondary
somatosensory cortex; SC, spinal cord; tACS, transcranial alternating current stimulation; tDCS, transcranial direct
current stimulation; vlPFC, ventrolateral prefrontal cortex.

highly promising target, given that opioids particularly
modulate the affective dimension of pain, but have not
been studied as widely as the brainstem–spinal cord axis
in terms of opioidergic modulation. The expression of
µ-​opioid receptors (MORs), which account for a major
proportion of opioidergic analgesia, is particularly dense
in cortical areas, including the ACC, the PFC and the
insula. For instance, the distribution and modulation of
opioid receptors in the ACC has been well described in
recent studies120,121.
Opioids dose dependently decrease pain-​related
blood oxygen level-​dependent signals independently
of opioid-​induced vascular changes and suppress
pain-​related potentials in humans in the insula, S1, S2
and ACC119,122 (Fig. 3). Functional near-​infrared spectros-
copy also revealed that the response of the entire mPFC
region (Brodmann area 10) and the contralateral S1 to
noxious stimuli is repressed by morphine in correlation
with drug plasma concentration123. Paradoxically, opi-
oids have also been linked to increased activity in the
ACC and the OFC, a region that has been suggested
to play a role in reward processing, during noxious
stimulation119.
The notion that opioids inhibit the aversive elements
of pain more strongly than its sensory component, par-
ticularly at lower doses, is consistent with reports that
low opioid doses are sufficient to fully block activa-
tion of the AI and other centres in the limbic system,
whereas increasing concentrations of opioids inhibit the
components of the nociceptive matrix, such as the S1
and S2 and the PI124. In animal models, seminal work by
Navratilova, Porreca and colleagues demonstrated that
activating opioid receptors specifically in the rACC,
using opioid doses lower than those that inhibit nocicep-
tive hypersensitivity, was sufficient to attenuate ongoing
neuropathic pain125. There is a dichotomy of opioider-
gic actions on pain affect (via the rACC‒NAc pathway)
and sensory qualities of nociception (via the RVM
descending axis)126. Opioidergic actions in the rACC
stimulate release of dopamine in the NAc125, indicating
activation of prefrontal–NAc connectivity and reward
pathways, and are, in turn, modified by the CeA127, thus

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suggesting a role for amygdala‒cingulate–striatal path-
ways in opioid analgesia. Opioidergic mechanisms in
the rACC have also been implicated in reduction of
ongoing pain by non-​opioidergic analgesic drugs,
including gabapentin128 and α2-​adrenergic agonists, such
as clonidine125. Opioidergic agonists microinjected into
the ventro-​orbital cortex reversed mechanical and cold
hypersensitivity after nerve injury via MORs129.
Cannabinoids
While cannabinoidergic actions at the level of periph-
eral mechanisms and spinal nociceptive transmission
are well described, insights into modulation of brain
pathways as a basis for cannabinoidergic analgesia are
only recently starting to emerge. In a human model of
acute pain, Δ9-​tetrahydrocannabinol reduced unpleas-
antness and ongoing pain in association with activa-
tion of the right amygdala and reduced connectivity
between the sensorimotor cortex and the amygdala130.
In patients with chronic radicular neuropathic pain,
Δ9-​tetrahydrocannabinol reduced functional connectiv-
ity between the ACC, the dlPFC and the sensorimotor
cortex in a manner predictive of the analgesic efficacy131
(Fig. 3). Thus, the emerging view is that cannabinoids
disrupt higher-​order sensorilimbic connections and
that the resting-​state strength of these connections may
be used as a predictive measure for cannabinoid-​based
therapies in clinical applications.
Ketamine and antidepressant drugs
Ketamine (or its S enantiomer, esketamine) is gaining
clinical prominence for its analgesic actions as well as
rapid-​onset and strong antidepressive qualities132. In ani-
mal models, ketamine has recently been demonstrated
to relieve depression-​related behaviours in neuropathic
mice, accompanied by restoration of depleted levels of
brain-​derived neurotrophic factor and neuroligins in the
PFC, ACC and hippocampus133. Interestingly, a low dose
of ketamine attenuates the aversive component of pain
for longer than its antinociceptive effect, which was also
tied to suppression of activity in the ACC73 (Fig. 3).
Antidepressant drugs, which act by blocking reuptake
of serotonin and noradrenaline and activating brainstem
descending inhibition, show significant clinical benefits
as analgesic and co-​adjuvants in neuropathic pain8,134.
Very little is known about how they modulate pain
affect, and given the high density of neocortical projec-
tions of brainstem serotonergic and noradrenergic neu-
rons, neocortical contributions deserve to be explored
in detail. Interestingly, a recent study demonstrated
that chemogenetic activation of prefrontally projecting
noradrenergic neurons located in the locus coeruleus
actually induced aversion and spontaneous pain rather
than eliciting antinociception135.
Non-​pharmacological therapies
Owing to problems with conventional analgesics, as
seen at worst in the current opioid crisis in the United
States with extensive use and harmful reliance on opi-
oid analgesics, there is growing interest in develop-
ing non-​pharmacological alternatives, particularly as
adjunct therapies to help lower the dose and frequency
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of analgesic drugs and thus reduce their side effects136.
Addressing the mechanisms and precise circuits under-
lying analgesia by neuromodulation therapies that target
cortical domains is now an exciting emerging field136.
Neurostimulation-​induced analgesia
As per the most recent clinical standpoint, evidence-
based guidelines indicate definite efficacy of high-
frequency non-invasive repetitive transcranial magnetic
stimulation (rTMS) of the contralateral M1 for allevi­
ating neuropathic pain and probable efficacy of
high-frequency rTMS of the left M1 for improving
quality of life or of the left dlPFC for alleviating pain in
patients with fibromyalgia136 (Fig. 3). Interestingly, neo-
cortical enhancement of supraspinal opioidergic inhibi-
tion may only partly account for the clinical efficacy of
neurostimulation. In rTMS of the M1, release of opioids,
but not of dopamine, is reported in diverse neocortical
areas, including the medial OFC, ACC, left insula and
dlPFC137, but transcranial direct current stimulation
of the M1 failed to lower the required opioid dosage138.
By contrast, analgesia induced by rTMS of the left dlPFC
has an opioid-​sparing effect138 and is inhibited by the
MOR antagonist naloxone139. More recently, manipula­
tion of somatosensory cortical alpha-band activity
using transcranial alternating current stimulation was
associated with lower levels of reported pain in both
healthy individuals140 and patients with chronic pain141,
suggesting that targeted oscillatory modulation with
transcranial alternating current stimulation could also
be harnessed for pain relief.
Rodent models involving direct (invasive) or trans-
dural electrical stimulation of the M1 implicate an
inhibition of neuronal activity in thalamic relay nuclei,
suggesting suppression of nociceptive signals in the
sensory neurons in the somatosensory pathway in
neuro­pathic rats, as well as disinhibition of neurons
in the PAG that mediate descending inhibition of
spinal nociception142.
Conditioned pain modulation
Conditioned pain modulation (CPM) refers to the phe-
nomenon of pain being inhibited by a conditioning
pain stimulus applied to another part of the body, and
recent data reveal the importance of neocortical regions
in modulating brainstem nuclei which ultimately elicit
CPM via suppression of spinal nociception143. CPM
is compromised in some forms of chronic pain, and a
meta-​analysis revealed deficits in CPM in patients with
chronic low-​back pain in a manner proportional to pain
chronicity144. CPM is associated with increased activity of
the OFC and the amygdala, followed by suppression
of typically pronociceptive brain regions, such as the
S1, S2 and insula145 (Fig. 3). Conversely, healthy individ-
uals lacking CPM analgesia in a paradigm of acute pain
demonstrate enhanced activation of the ACC and the
PFC146.
Cognitive control of pain
Given that expectancy and attentional factors can
strongly modulate pain perception, there has been rising
interest in exploring the use of cognitive manipulation
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for reducing perceived pain and elucidating the neural
underpinnings thereof. While activation of endogenous
opioidergic pathways has been implicated in several
cognitive strategies for pain control, including placebo
analgesia, hypnosis and attentional control147, there are
substantial reports on opioid-​independent mechanisms,
such as in mindfulness meditation-​induced analgesia148.
There is mounting evidence for a critical role for path-
ways originating in the neocortex in emerging cognitive
strategies for pain relief.
Placebo analgesia. Placebo analgesia can be inhibited
by naloxone, which acts by hindering coupling between
the rACC and the PAG in placebo responders149 (Fig. 3),
indicating involvement of descending modulation of
nociception. However, recent human studies essentially
implicate opioidergic pathways as well as cortical circuits
governing expectation and conditioned learning, orig-
inating mainly from diverse PFC domains, in placebo
analgesia. Although suppression of the S2 and other, typ-
ically ‘nociceptive’ cortical regions has been reported in
placebo analgesia150,151, the neurologic pain signature2 is
modulated by placebo treatment to a minor extent only,
suggesting that the mechanisms underlying placebo anal-
gesia transcend modulation of nociceptive processing152.
Moreover, placebo responders show enhanced functional
connectivity of the rACC not only with the PAG but also
with the amygdala, thus implicating neocortical modu-
lation of subcortical structures governing conditioned
learning153. Direct comparison of brain regions acti-
vated during opioid treatment versus placebo analgesia
revealed rACC activation in both; however, the lateral
OFC and the ventrolateral PFC show stronger activation
during responsivity to placebo treatment than during
opioid analgesia154, consistent with their role in the pro-
cessing of expectation and error signals and contextual
evaluation of sensory stimuli. The mPFC and the lateral
PFC are activated during anticipation of placebo analge-
sia, while the right PFC and the dlPFC are most strongly
activated during placebo analgesia150 (Fig. 3). A recent
study used gabapentin-​induced, naloxone-​sensitive
Pavlovian conditioning to model placebo analgesia in
rodents and reported enhanced activity in the PL domain
of the PFC, the NAc and the ventrolateral PAG155, thereby
opening up perspectives for functionally interrogating
circuits underlying placebo analgesia.
Mindfulness and self-​regulation. Mindfulness meditation
has been reported to suppress pain intensity and unpleas-
antness and use brain mechanisms distinct from those
used in placebo analgesia150, including a stronger activation
of the OFC, subgenual ACC and AI, which are primarily
associated with cognitive and affective modulation of
pain and interoceptive awareness150 (Fig. 3). The strength
of intrinsic connectivity in the frontoparietal network,
consisting of the PFC and parietal cortex, and the rACC/
mPFC, is suggested to predict and shape expectancy-​
induced modulation of pain156. Woo et al.157 found that
self-​regulation to enhance or suppress pain in response
to acute noxious stimuli does not influence the neuro-
logic pain signature, but rather uses a frontostriatal path­
way between the ventromedial PFC and the NAc, a
pathway that has been implicated in emotional appraisal.
Summary and outlook
Taken together, recent studies using modern circuit
interrogation tools have unveiled critical insights into
how individual neocortical domains process incoming
noxious and non-​noxious inputs and scale them to create
pain perceptions of various intensities and aversive qua­
lities via interactions with other cortical and subcortical
structures. While the emerging picture supports the con-
cept that pain is essentially the functional product of a
broad and redundant network of brain structures, there
is also mounting evidence for functional segregation of
distinct aspects of sensory coding, intensity coding, aver-
sion and negative affect across neocortical domains and
specific pathways, with important differences between
acute and chronic pain and between inflammatory and
neuropathic pain.
This knowledge, however, is by no means complete,
and the much-​needed fine-​grained analysis of specific
circuits linking cells to behaviour will need to continue
and be extended to new studies to unravel how attention,
expectation, anxiety, fear and stress modulate and shape
the experience of pain, given their importance in pain
chronicity. In the neocortex, encoding of pain modalities
in neuronal ensembles and signal processing and modu­
lation in precisely organized laminar columns remains
to be elucidated. Moreover, there are a number of seem-
ingly paradoxical findings that require clarification, and
a further cellular delineation of pathways promoting
pain versus those fostering pain relief is key to achieving
therapeutic success. As knowledge of neural specificities
of neocortical efferent pathways controlling pain accrues
from rodent models, a major challenge ahead is to use
these insights to increase the efficacy and improve the
safety of non-​pharmacological neurostimulation-​based
and neuromodulation-​based therapies. Finally, the bur-
geoning knowledge of neocortical circuits can also pave
the way for designing novel pharmacological therapies
if it is supplemented by detailed analyses of molecular,
genetic and epigenetic mechanisms underlying signal-
ling specificity and plasticity. Here, a critical basis for
specific cell-​targeted therapies could be achieved via
application of the newly developed single-​cell transcrip-
tomics and epigenomics technologies to key neocortical
circuits in future studies.
Published online 14 June 2021

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Acknowledgements
The authors thank all members of their laboratory as well as
scientists in the Heidelberg Pain Consortium (CRC1158 of the
Deutsche Forschungsgemeinschaft) for thought-​provoking
discussions and expert viewpoints. The authors acknowledge
funding to R.K. from the Deutsche Forschungsgemeinschaft
in the form of grants for Collaborative Research Centre 1158
(projects B01 and B06) and from the Baden-​Württemberg
Foundation (Internationale Spitzenforschung; BWST-​
ISF2017-069). L.L.T. was partially supported by a postdoc-
toral fellowship from the European Molecular Biology
Organization. R.K. is a member of the Molecular Medicine
Partnership Unit in the Medical Faculty in Heidelberg and the
European Molecular Biology Laboratory.
Author contributions
Both authors contributed equally to all aspects of this work.
Competing interests
The authors declare no competing interests.
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Reviewer information
Nature Reviews Neuroscience thanks Elizabeth May, who
co-​reviewed with Markus Ploner; Patrick Sheets; and Gregory
Scherrer for their contribution to the peer review of this work.
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