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  • Writer's pictureDr. Harold Pierre

Understanding Chronic Pain in Mast Cell Activation Syndrome (MCAS)

Updated: Dec 11, 2023

Understanding Chronic Pain in Mast Cell Activation Syndrome (MCAS)

Have you ever come across the term Mast Cell Activation Syndrome, often abbreviated as MCAS? For many, it might be a new term, but for those diagnosed, it's a daily reality. Imagine facing a health condition that's not just an allergic reaction or a fleeting symptom but a continuous battle. This is the world of MCAS, a systemic mast cell activation disease that intertwines with chronic pain, inflammation, and a myriad of other symptoms. As a trusted anesthesiologist and addiction medicine specialist in the Tulsa community, I've had the privilege of understanding and empathizing with MCAS patients. Their stories, their challenges, and their resilience have inspired this article. So, whether you're listening to gain knowledge, find solace, or simply to understand a loved one better, let's embark on this journey together to unravel the mysteries of MCAS and chronic pain.

The Science Behind Mast Cells and Pain:

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At the center of MCAS are the microscopic mast cells, present throughout bodily tissues. Mast cells are present throughout bodily tissues, concentrated near blood vessels, nerves, and surfaces exposed to the external environment like the skin and gut. When they perceive danger - be it pathogens, venoms, allergens, or toxins - mast cells spring into action!

They serve vital protective roles through:

  • Pathogen Defense - Mast cells detect invading bacteria and viruses, releasing substances to recruit other immune cells.

  • Venom/Toxin Response - They detect noxious compounds and initiate a neutralizing response.

  • Wound Healing - Mast cell mediators signal to other cell types, initiating tissue repair.

  • Allergic Response - They detect allergens and orchestrate reactions like swelling and itching to expel the intruder.

These tiny titans contain granules packed with over 200 potent chemical messengers, including:

  • Histamine - causes vasodilation, nerve sensitization, hives, swelling, and flushed skin. Histamine signaling through H1 and H2 receptors contribute to pain hypersensitivity.

  • Proteases - Enzymes like tryptase and chymase directly activate receptors such as PAR2 on sensory neurons, inflicting inflammatory pain. Proteases also modulate TRPV1 and TRPA1 ion channels to enhance pain signaling..

  • inflammation. - call reinforcements, summoning immune cells to act.

  • Growth factors - Nerve growth factor (NGF) elicits mast cell degradation and sensitizes nociceptors. Growth factors also stimulate repair and regeneration of tissues.

  • Cytokines - Pro-inflammatory cytokines like IL-1β, IL-6, TNF-α secreted by activated mast cells mediate pain by increasing nerve excitability.

  • Neuropeptides - Mast cell mediators like substance P further amplify neurogenic inflammation and pain.

  • Prostaglandins - sensitize nerve endings, amplifying pain signals.

This incredibly versatile arsenal allows mast cells to modulate diverse processes from jump-starting wound healing to cranking up pain receptors. So what happens when your own mast cell defenders spin out of control? Buckle up, the storms are gathering...

Mast Cell Activation Syndrome: When Guardians Overreact

In healthy individuals, mast cells respond appropriately to threats. But for Mast Cell Activation Syndrome (MCAS) patients, these cells have impaired control mechanisms and release mediators persistently or in excess.

Triggers are often benign substances like foods, chemicals, odors, medications, temperature changes, or even stress. Once activated, the cascade of mast cell mediators leads to chronic, systemic symptoms affecting:

  • Cardiovascular - Flushing, low blood pressure

  • Dermatological - Hives, swelling

  • Gastrointestinal - Pain, diarrhea

  • Neurological - Headaches, brain fog

  • Respiratory - Throat tightness, wheezing

  • Musculoskeletal - Joint/muscle pain

  • Immunologic - live threatening anaphylaxis

Mast Cell Activation Syndrome (MCAS) paints a picture of what happens when mast cells become overly sensitive. In MCAS, these cells release their mediators excessively or without an appropriate trigger, leading to a spectrum of symptoms. The systemic nature of MCAS implies its effects aren't confined to one region. From dermatological symptoms like hives to gastrointestinal issues like abdominal pain, MCAS's reach is extensive.

Chronic Pain Conditions: The Unseen Agony of MCAS

Among the myriad symptoms of MCAS, chronic pain stands out as particularly debilitating. But how does an overactive mast cell translate to pain? The mediators, when released in abundance, incite inflammation. This inflammation can manifest diversely: from joint pain reminiscent of arthritis to back pain and migraines. Given the systemic character of MCAS, this pain isn't localized but mirrors the widespread activation of mast cells.

Moreover, the pain isn't merely a physical manifestation. The emotional and psychological burden of enduring unexplained, often invalidated pain, is profound. For many MCAS patients, the challenge isn't just physiological but also involves battling societal misconceptions.

The Diagnostic Labyrinth

Arriving at an MCAS diagnosis is akin to navigating a maze. The symptoms overlap with numerous conditions, from fibromyalgia to irritable bowel syndrome, making it a diagnostic challenge. Criteria encompass a blend of clinical manifestations, elevated mediator levels, and a positive response to treatments like antihistamines. For many, achieving a definitive diagnosis is an odyssey, punctuated with trials, errors, and endless perseverance.

The Broader Implications

The study of MCAS doesn't just benefit those diagnosed. It offers insights into the role of mast cells in other conditions. For instance, their involvement in conditions like asthma, where inflammation plays a key role, is under rigorous investigation. Mast cells have in implicated in other pain syndromes. Furthermore, understanding MCAS underscores the importance of personalized medicine. What works for one MCAS patient might not for another, highlighting the need for tailored therapeutic approaches.

Diving into the Types of Chronic Pain in MCAS:

Skin rashes, allergies contact dermatitis, allergic to chemicals, fungal infections from exposure, hives on skin, Mast Cell Activation Syndrome

Mast Cell Activation Syndrome (MCAS) is a condition that manifests in a myriad of ways, with chronic pain being one of its most pronounced symptoms. The types of pain MCAS patients experience are as diverse as the locations of mast cells in the body. Let's explore the spectrum of pain associated with MCAS.

Musculoskeletal Pain:

  • This is one of the most commonly reported pains. It can feel like a persistent ache in the muscles or a sharp pain in the joints. Conditions like fibromyalgia, characterized by widespread musculoskeletal pain, often have overlapping symptoms with MCAS.

Neuropathic Pain:

  • Originating from the nervous system, patients describe this as a burning, tingling, or electric shock-like sensation. Given the proximity of mast cells to nerves, their activation can directly influence nerve function.

Abdominal and Pelvic Pain:

  • The gastrointestinal and pelvic regions are rich in mast cells. Activation in these areas can lead to cramps, bloating, bladder symptoms, menstrual pain, and pain during intercourse. Pelvic pain, in particular, can be debilitating and is often associated with conditions like interstitial cystitis or endometriosis.

Headaches and Migraines:

  • Many MCAS patients suffer from frequent and severe headaches, with some progressing to migraines. The role of mast cells in inflammation and vascular changes might be a contributing factor.

Chest Pain:

  • This can be alarming, as it's sometimes mistaken for cardiac symptoms. However, in MCAS, it might be due to esophageal spasms or inflammation in the chest region.

Skin Pain:

  • Beyond itching and hives, some patients experience a distinct burning or stinging sensation, often without any visible signs.

Bone Pain:

  • This deep-seated pain can be intermittent or persistent, adding another layer to the complex pain profile of MCAS.

Ear and Throat Pain:

  • Activation of mast cells in the ear and throat can lead to pain or discomfort, sometimes mimicking infections or other ENT conditions.

Eye Pain:

  • Symptoms like conjunctivitis, leading to eye pain, itching, and redness, can be attributed to mast cell activation in some cases.

Understanding the Mast Cell Connection and the Mediators

Mast cells, when activated, release a plethora of mediators. While histamine is the most recognized, others like prostaglandins and cytokines play direct roles in pain and inflammation. For instance, prostaglandins can sensitize nerve endings, amplifying pain signals. On the other hand, cytokines, involved in inflammation, can exacerbate pain when produced in excess.

The Emotional and Psychological Impact

Living with chronic pain, especially from a condition as multifaceted as MCAS, is not just a physical challenge. The emotional toll, stemming from the unpredictability of flare-ups and societal misconceptions about "invisible" illnesses, is profound. The journey to diagnosis, often long and winding, further compounds the emotional strain.

The diverse pain experiences of MCAS patients underscore the complexity of this condition. As we continue to explore MCAS, it's essential to recognize the profound impact of chronic pain on patients' lives. Behind every symptom is a story of resilience, hope, and determination.

Managing and Treating Chronic Pain in MCAS:

Living with Mast Cell Activation Syndrome (MCAS) is a daily challenge, with chronic pain being one of its most debilitating symptoms. Managing this pain requires a multifaceted approach, combining conventional medical treatments with alternative therapies and immunological interventions. Here's a comprehensive guide to navigating pain management for MCAS.

Conventional Medical Treatments:


  • Often the first line of defense against MCAS symptoms. By blocking the effects of histamine, they can reduce inflammation and associated pain.

Mast Cell Stabilizers:

  • Medications like cromolyn sodium prevent the release of mediators from mast cells, reducing symptoms.

Pain Relievers:

  • Over-the-counter options like acetaminophen or NSAIDs can be effective for some. However, some MCAS patients might be sensitive to specific medications.


  • Used to reduce inflammation and have immunosuppressive effects, beneficial for severe cases.


  • Offers potential benefits for neuropathic pain due to its anti-inflammatory properties. In my experience, ketamine can be a game changer for most.

Tricyclic Antidepressants (TCAs) and SNRIs:

  • Beneficial for neuropathic pain, migraines, and co-existing depressive symptoms.


  • Potent pain relievers used with caution due to potential side effects and dependency risks. If this option is used, consider starting with a buprenorphine product like Butrans.

Alternative and Complementary Therapies:

Dietary Changes:

  • Identifying and eliminating trigger foods can provide relief.


  • An ancient practice that can help alleviate various pain conditions.


  • Teaches patients to control physiological functions, aiding in pain management.

Physical Therapy:

  • Tailored exercises and stretches can help with musculoskeletal pain.

Mindfulness and Meditation:

  • Focuses on the present moment, helping patients develop coping mechanisms and reduce stress.

Herbal Remedies and Aromatherapy:

  • Natural treatments like quercetin or essential oils can offer relief. However, scents are common triggers for MCAS patients and caution should be taken during aromatherapy.

Immunological Therapies:

Omalizumab (Xolair):

  • A monoclonal antibody that targets IgE, reducing mast cell activation.

Intravenous Immunoglobulin (IVIG):

  • Modulates the immune response, offering potential symptom relief.

Cyclosporine and Methotrexate:

  • Immunosuppressive drugs that can modulate the immune response, reducing mast cell activation.

Biologic Therapies:

  • Target specific immune pathways, offering promise for future treatments. There are many compounds in clinical trials at this moment. I think a major breakthrough will occur within the next 5 years.


  • A chemotherapy drug used as a cytoreductive therapy in systemic mastocytosis, reducing the number of mast cells and alleviating symptoms.

Personalized Treatment and Support:

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MCAS is a highly individualized condition. Adopting a personalized approach, considering the patient's unique symptoms, triggers, and overall health is crucial. Regular monitoring and adjustments to the treatment plan are essential for optimal results. Beyond medical treatments, support and education play a pivotal role in managing MCAS. Joining support groups, attending workshops, and staying informed can empower patients and improve their quality of life.

Impact of Chronic Pain in MCAS on Daily Life:

Living with Mast Cell Activation Syndrome (MCAS) is not just about managing physical symptoms. The chronic pain associated with MCAS can profoundly impact every facet of a patient's life, from daily routines to mental well-being. Here's a deep dive into the multifaceted repercussions of chronic pain in MCAS:

Physical Limitations:

  • Activities once taken for granted, like climbing stairs or lifting objects, can become challenging. Simple tasks such as grocery shopping or household chores might require planning and pacing.

Sleep Disturbances:

  • Chronic pain can disrupt sleep patterns, leading to insomnia or frequent awakenings. Over time, sleep deprivation can exacerbate pain and affect cognitive functions.

Mental and Emotional Strain:

  • Constant pain can lead to feelings of frustration, anxiety, and depression. The unpredictability of MCAS flare-ups can heighten feelings of uncertainty and fear.

Social Implications:

  • Social activities might be curtailed due to pain or the fear of triggering a flare-up. This can lead to feelings of isolation and a reduced support system.

Work and Productivity:

  • Chronic pain can impact work performance, leading to reduced hours or even job loss. This can have financial implications and affect self-worth.

Relationships and Family Dynamics:

  • Loved ones might struggle to understand the invisible pain MCAS patients endure. This can strain relationships, with patients feeling misunderstood or unsupported.

Cognitive Impact:

  • Often referred to as "brain fog," chronic pain can affect concentration, memory, and decision-making abilities.

Financial Strain:

  • Medical appointments, treatments, and medications can be costly. Combined with potential work limitations, this can lead to financial stress.

Navigating the Healthcare System:

  • Seeking a diagnosis, understanding the condition, and finding effective treatments can be a journey in itself. Patients often see multiple specialists and undergo numerous tests, which can be time-consuming and emotionally draining.

Self-Identity and Self-Worth:

  • Chronic pain can change how patients view themselves. They might grieve for their "pre-MCAS" life and grapple with feelings of inadequacy or guilt.

Finding Resilience and Hope:

While the impact of chronic pain in MCAS is undeniable, many patients find resilience in their journey. Through support groups, therapy, and self-advocacy, they build a network of understanding and hope. By sharing their stories, they not only find personal healing but also pave the way for greater awareness and understanding of MCAS in the broader community.

Coping Strategies and Support for MCAS Patients with Chronic Pain:

Living with the chronic pain of Mast Cell Activation Syndrome (MCAS) is a daily challenge, but with the right strategies and support, patients can find relief and improve their quality of life. Here are some coping mechanisms and resources tailored for MCAS patients:

Pain Management Techniques:

  • Deep Breathing and Meditation: These practices can help divert attention from pain and induce relaxation.

  • Guided Imagery: Visualizing peaceful and calming scenes can reduce stress and pain levels.

  • Progressive Muscle Relaxation: Tensing and then relaxing each muscle group can alleviate tension.

Physical Activity:

  • Gentle Exercises: Activities like walking, swimming, or yoga can help maintain muscle tone and reduce pain.

  • Physical Therapy: Tailored exercises can address specific pain areas and improve mobility.

Dietary Adjustments:

  • Identifying and avoiding trigger foods can reduce MCAS flare-ups and associated pain.

Emotional and Psychological Support:

  • Counseling and Therapy: Talking to a professional can provide coping strategies and emotional support.

  • Support Groups: Connecting with others who understand the challenges of MCAS can offer comfort and shared experiences.

Educate Yourself:

  • Understanding MCAS and its implications can empower patients to advocate for their health.

Establish a Routine:

  • Keeping a consistent daily routine can provide a sense of normalcy and predictability.

Stay Connected:

  • Maintaining relationships with loved ones can offer emotional support and reduce feelings of isolation.

Use of Assistive Devices:

  • Tools like ergonomic chairs, special pillows, or mobility aids can make daily tasks more manageable.

Keep a Symptom Journal:

  • Tracking symptoms, triggers, and effective treatments can provide valuable insights and aid in medical consultations.

Seek Out Reliable Information:

  • Rely on reputable sources for MCAS information, avoiding misinformation that can lead to anxiety.

  1. Advocate for Your Health: Don't hesitate to seek second opinions, ask questions, or request specific tests or treatments.

  2. Relaxation Techniques: Activities like reading, listening to music, or taking warm baths can offer respite from pain.

  3. Stay Hopeful: While living with MCAS is challenging, medical advancements and increased awareness offer hope for better treatments and understanding in the future.

Coping with the chronic pain of MCAS requires a combination of medical interventions, self-care, and emotional support. By adopting these strategies and seeking out a supportive community, MCAS patients can navigate their condition with resilience and hope.

The Future of MCAS Research and Hope for Patients:

Research team with one person pointing with pen near other scientists in neon lit futuristic science center, banner copy

The journey of understanding and managing Mast Cell Activation Syndrome (MCAS) has been a complex one, marked by both challenges and breakthroughs. As researchers delve deeper into the intricacies of this condition, there's growing optimism about the future. Here's a glimpse into the ongoing research and the hope it brings for MCAS patients:

Advancements in Diagnostic Tools:

  • Biomarker Research: Scientists are exploring specific biomarkers that can provide a more definitive diagnosis of MCAS, reducing the current reliance on clinical symptoms alone.

  • Genetic Insights: With advancements in genetic sequencing, researchers are identifying potential genetic markers associated with MCAS, paving the way for personalized treatments.

Exploring New Treatments:

  • Targeted Therapies: As our understanding of mast cell biology deepens, there's potential for treatments that target specific pathways involved in mast cell activation.

  • Immunotherapies: Building on the success of treatments like omalizumab, researchers are exploring other immunological interventions that can modulate the immune response in MCAS patients.

Understanding Triggers and Mechanisms:

  • Environmental Factors: Studies are underway to understand the environmental triggers, such as pollutants or dietary components, that might exacerbate MCAS symptoms.

  • Mast Cell Interactions: Research is focusing on how mast cells interact with other cells and systems in the body, providing insights into the systemic nature of MCAS.

Collaborative Research Efforts:

  • Global Initiatives: Research institutions worldwide are collaborating, sharing data, and pooling resources to accelerate MCAS research.

  • Patient Registries: By collecting detailed data from MCAS patients, these registries provide invaluable insights into the condition's variability and progression.

Patient Advocacy and Awareness:

  • Community Initiatives: MCAS patients and advocates are playing a crucial role in raising awareness, driving research funding, and ensuring that the patient perspective is central to research efforts.

  • Educational Programs: Initiatives are underway to educate healthcare professionals about MCAS, ensuring timely diagnosis and appropriate care.

Holistic Approaches to Care:

  • Recognizing that MCAS affects multiple systems in the body, there's a move towards integrated care approaches that address both physical and mental well-being.

While challenges remain, the future of MCAS research is promising. With the combined efforts of researchers, clinicians, patients, and advocates, there's hope for more effective treatments, better diagnostic tools, and a deeper understanding of MCAS. For patients navigating the complexities of this condition, these advancements offer a beacon of hope for a brighter, pain-free future.

Key Takeaways on MCAS and Chronic Pain

Understanding MCAS:

  • Mast Cell Activation Syndrome (MCAS) is a condition where mast cells inappropriately release chemical mediators, leading to a range of symptoms, including chronic pain.

Mast Cells and Pain:

  • Mast cells play a crucial role in the body's immune response.

  • Their inappropriate activation can lead to inflammation and pain.

Types of Chronic Pain in MCAS:

  • MCAS patients can experience various pain types, including musculoskeletal, neuropathic, abdominal, and pelvic pain.

Treatment Options:

  • A combination of conventional medications, alternative therapies, and immunological treatments can help manage pain.

  • Personalized treatment plans are essential for optimal results.

Daily Life Impact:

  • Chronic pain can affect physical activities, sleep, mental well-being, social interactions, and work productivity.

Coping and Support:

  • A combination of medical interventions, self-care, emotional support, and education can help patients navigate their condition.

Future Research and Hope:

  • Advancements in diagnostic tools, treatments, and understanding of MCAS offer hope for patients.

  • Collaborative research efforts and patient advocacy play a pivotal role in driving progress.

Mai, L., Liu, Q., Huang, F., He, H., & Fan, W. (2021). Involvement of Mast Cells in the Pathophysiology of Pain. *Frontiers in Cellular Neuroscience*.

Wirz, S. & Molderings, G.J. (2017). A practical guide for treatment of pain in patients with systemic mast cell activation disease. Pain Physician, 20(6), E849-E861.

About the author:

Dr. Harold Pierre is a board-certified anesthesiologist and addiction medicine specialist with over 20 years of experience. He is board-certified by the American Board of Anesthesiology and the American Board of Preventive Medicine.

This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease, and those seeking personal medical advice should consult with a licensed physician or another qualified medical professional. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

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