As with everything else with this nutty disease, nothing seems to be absolute. I've had flares with no pain proceeding it, and I've had others where I've had ice pick headaches in the same area as the new leisons.

My neuro just goes "hmmm" and jots it down. My own theory (and it's just mine, I'm no doc ) is that because my new leisons flare and go inactive so quickly it causes some pain. During my DX process, I slowly increased from 4 to 9 leisons in my brain over the course of a year. Never active under contrast.