This document discusses, among other things, systems and methods for managing pain in a subject. A system may include one or more sensors configured to sense from the subject information corresponding to emotional reaction to pain, such as emotional expression. The emotional expression includes facial or vocal expression. A pain analyzer circuit may generate a pain score using signal metrics of facial or vocal expression extracted from the sensed information. The pain score may be output to a user or a process. The system may additionally include a neurostimulator that can adaptively control the delivery of pain therapy by automatically adjusting stimulation parameters based on the pain score.