Almost everyone knows neck pain: a stiff neck after a restless night, a dragging ache towards the shoulder after a long day at the screen. The great majority comes from tense muscles and irritated vertebral joints and passes by itself. This page explains what can lie behind it, how we recognise the few causes that need a targeted treatment, what you can do yourself, and when you should not wait.
Fewer than one in a hundred cases of neck pain has a dangerous cause. The task of the first examination is not to take an image, but to recognise that one case — and to keep the rest moving.
What lies behind neck pain
Almost half of all adults have neck pain at least once a year, women more often than men. In most of them no single structure can be named as the cause; medicine speaks of non-specific neck pain. That does not mean “imagined” but this: the pain comes from muscles, ligaments and small vertebral joints that are overloaded, tense or irritated. Stress and lack of sleep make it stronger. In a smaller proportion a specific cause is found: a herniated disc pressing on a nerve root, worn vertebral joints, a narrowing of the spinal canal which in the worst case puts pressure on the spinal cord; more rarely injuries, infections, rheumatic conditions and tumours. And occasionally a “neck pain” does not come from the neck at all, but from the shoulder, the jaw joint, the vessels of the neck or — with fever and a stiff neck — from the meninges. According to the guideline for general practice, fewer than 1 in 100 cases of neck pain goes back to a dangerous underlying condition.
How we tell where it comes from
The conversation contributes most. Since when, how did it start? Does it run into the arm — and into which fingers? Is there tingling, numbness, weakness, clumsy hands, an unsteady gait? What makes it worse — turning, tilting, looking upwards, the night? Was there a fall, fever, unintended weight loss, a cancer, a course of cortisone, osteoporosis? Then the examination: mobility of the head, tenderness to pressure and to tapping, strength of the arm and hand muscles, reflexes, sensation, fine motor skills, walking pattern. Almost always a clear direction emerges from this before any image has been taken. For acute neck pain with no pointer to a structural cause, the guideline recommends no imaging, and X-rays not as a first step even when a cause is being looked for — for that, the MRI scan is the right method. An image becomes sensible with warning signs, with nerve deficits, and when the symptoms are no better after four to six weeks despite treatment. The reason: from middle age onwards, images of the cervical spine show signs of wear in almost everyone that have nothing to do with the symptoms.
The most common causes
Non-specific neck pain
The great majority. Typical: a dull or dragging pain, often one-sided, worse in the morning or after long sitting, with hardened muscles between the neck and the shoulder blade, restricted turning of the head and sometimes a tension headache running from the back of the head to the forehead. No tingling, no numbness, no weakness.
Herniated disc and irritated nerve root
Typical: a sharp, electric pain that runs from the neck over the shoulder blade into the arm and follows a strip down to particular fingers, worse on tilting the head towards the painful side. With it tingling or numbness in the same strip, sometimes a weakness at the elbow or in making a fist. The arm pain is usually stronger than the neck pain. In older people a wear-related narrowing of the nerve exit opening is more often the cause. More on the page Herniated disc of the cervical spine.
Cervical myelopathy
If the spinal canal becomes so narrow that the spinal cord is under pressure, the signs are quiet: clumsy hands that no longer manage buttons, keys and handwriting reliably, tingling in both hands or feet, a broad-based, unsteady gait, and later a problem passing water. These signs need to be assessed promptly, because lost spinal cord function does not reliably come back. More on the page Cervical myelopathy.
Worn vertebral joints
Typical: from middle age onwards, a deep neck pain on turning the head and on looking upwards, stiff in the morning, with radiation to the back of the head, into the shoulder or between the shoulder blades, without tingling or weakness. More on the pages Facet joint osteoarthritis and Spinal stenosis.
Rare but important causes
Injury — after a rear-end collision or a fall, neck pain usually comes from strained muscles and ligaments; a severe pain after an accident nevertheless belongs in medical hands, especially with osteoporosis, a course of cortisone or rheumatic disease. Infection — a bacterial infection of disc and vertebra causes an increasing pain that persists at night as well, often with fever; a stiff neck with fever, headache and sensitivity to light can come from the meninges. Rheumatic disease — rheumatoid arthritis can attack the upper cervical spine and make it unstable. Tumour — an unremitting pain at night in someone with a known cancer, with weight loss or night sweats, points to a spinal metastasis. Blood vessels — a sudden, unfamiliar, one-sided neck and head pain with dizziness, a disturbance of vision or speech, or weakness down one side of the body can come from a tear in a carotid artery and is an emergency.
- Broad across the neck, tense, no arm, no tinglingPoints to non-specific neck pain.
- A strip down to particular fingers, tilting the head makes it worsePoints to the disc or a narrow root opening.
- Clumsy hands, unsteady gait, little painPoints to pressure on the spinal cord — to be assessed promptly.
- After an accident, with fever, at night, with weight lossPoints to injury, infection or tumour — to be assessed.
- Sudden, one-sided, with dizziness, disturbance of vision or speechPoints to the vessels of the neck — emergency services.
These patterns are rules of thumb, not diagnoses — we make the attribution together after the examination. More than one cause at the same time is possible.
Warning signs
With some signs, neck pain is not a case for the waiting list but for the emergency services: a weakness in the arm, hand or leg that increases within hours or days; a new problem passing water or opening the bowels; a sudden, unusually fierce neck and head pain with dizziness or a disturbance of vision, speech or swallowing; a stiff neck with a high fever. You should have the following assessed within a few days: new clumsiness of the hands or an unsteady gait, pain that runs into the arm together with loss of strength, pain after a fall or an accident, pain with fever, a new neck pain with a cancer, osteoporosis or rheumatic disease, pain with unintended weight loss, and pain that does not ease at night and at rest. More on the page Warning signs.
What you can do now
- Keep moving. Taking it easy and immobilising make the symptoms last longer. Move your head within the pain-free range, go for walks, stay active in daily life. The guideline recommends physical activity as the most important measure, together with warmth (or cold, if that feels better) — and advises against immobilisation. A neck collar, if at all, only for a few hours a day and for no longer than one to two weeks.
- Exercises for the neck and shoulder girdle. Gentle stretching of the side neck muscles, shoulder circles, strengthening of the muscles between the shoulder blades. For chronic neck pain the benefit of strengthening and stretching exercises is best established; which exercise matters less than doing it regularly.
- Painkillers, targeted and brief. An anti-inflammatory medicine such as ibuprofen or diclofenac for a few days at the lowest effective dose, provided nothing speaks against it — so that you can move. Muscle-relaxing medicines are not recommended by the guideline. Ask at your GP practice or pharmacy what fits with your other medicines.
- Movement at your workplace. Whether a particular chair or monitor prevents neck pain is not established. What is established is the benefit of movement: change your sitting position, get up every half hour, do not keep your head bent towards the screen or down at your phone.
- Pillows in proportion. On pillows there are only small studies; a review found indications of a small benefit from shape-retaining pillows, but no robust evidence for any particular product. Neither the guideline nor the IQWiG makes a recommendation on this. Rule of thumb: lying on your side, your head should rest in line with your spine and not bend away from it.
- Check the hands. Once a day: close your fist, spread your fingers, do up buttons. If that gets weaker or clumsier, get in touch.
When you should make an appointment
If the pain is not clearly better after about two to four weeks, if it runs into the arm or tingling, numbness or weakness are added, if your hands become clumsy or your gait unsteady, if it stops you sleeping or working, or if you simply want to know where it comes from. You need neither a referral nor an MRI scan for that; bring what you have, and come even if you have nothing. What happens at the first appointment is on the page Your first appointment.
How it usually goes on
Acute non-specific neck pain usually settles within one to two weeks; the majority of those affected are free of symptoms after four to six weeks. The guideline distinguishes acute pain up to three weeks, subacute up to twelve weeks and chronic beyond that; with chronic symptoms the treatment shifts towards regular training, supervised exercise therapy and dealing with load and stress. A root pain from a herniated disc takes longer, but in most of those affected it resolves over weeks to months without an operation. During this time a targeted injection at the irritated nerve root (PRT) can bridge the pain; it does not replace movement. An operation is not the first step with any form of neck pain — and with non-specific neck pain it is no step at all. It is different only with cervical myelopathy, where surgery is performed earlier. If you have been advised elsewhere to have a procedure and you are unsure, you can obtain a second opinion from us.
Frequently asked questions
Do I need an MRI scan?
Usually not. Without radiating pain, tingling, numbness, weakness and warning signs, the guideline recommends no imaging, because it does not change the treatment and produces incidental findings that cause worry. An MRI scan becomes sensible with nerve deficits, with warning signs, or when the symptoms are no better after four to six weeks despite treatment.
May I have my neck manipulated?
Manipulation (“clicking the neck back into place”) and mobilisation can ease things in the short term; the studies show no lasting advantage over movement and exercises. Very rarely, injuries to the vessels of the neck with a stroke have been described after manipulation of the cervical spine. With nerve deficits, signs of pressure on the spinal cord, osteoporosis, a rheumatic condition or an unexplained cause, manipulation has no place.
The matching conditions
- Herniated disc of the cervical spine — the pain that runs into the arm: waiting, injections, surgery.
- Cervical myelopathy — the spinal cord under pressure, with the quiet signs in the hands and the gait.
- Facet joint osteoarthritis and Spinal stenosis — wear of the vertebral joints and narrowing of the spinal canal.
- Warning signs — when you should not wait for an appointment.
With a rheumatic, inflammatory or vascular cause, and with pain coming from the shoulder, the jaw or the heart, we refer you on to the appropriate speciality — the examination that establishes this takes place with us.