Neck pain

Most adults get neck pain at least once, and it nearly always ends well: an awkward sleeping position, a long day at a screen, a draught, a pulled muscle — gone in days or weeks. It is that "nearly always" which makes neck pain dangerous to underrate. Among a hundred ordinary cases there are the ones where the same pain is caused by meningitis, a fracture, compression of the spinal cord or a torn artery, and they are told apart not by how badly it hurts but by what comes with it. This page is about separating the two, and along the way about why, for ordinary neck pain, a collar and rest are yesterday's advice.

What usually happens to the neck

The neck holds up a head the weight of a decent watermelon and still has to turn freely in every direction. The price of that mobility is a great many small joints, ligaments and muscles that are easy to overload. Hence the familiar scene: someone wakes with pain and cannot turn their head one way, or the pain builds through a day at the computer, or it started a day after their car was shunted from behind.

In most cases the specific culprit is never identified, and that is fine. The pain arises from muscles, from the joints between vertebrae, from ligaments and from the discs all at once; there is no way to apportion the blame and no need to, because the treatment is the same either way. Pain like this is called non-specific, and it settles on its own — acute pain usually within days or weeks.

Cervical spondylosis deserves a paragraph of its own. Changes in the discs and small joints show up on scans in almost everyone past forty; most of those people have no neck pain at all, while in people with severe pain the scan often looks unremarkable. In other words, a finding on an X-ray or an MRI does not by itself make a diagnosis or change the outlook. Something else matters far more: how the pain behaves, what makes it worse, and whether anything besides pain has appeared. Those are the questions worth your attention, not the wording of a scan report.

When to call an ambulance

Call an ambulance on the single European number 112 if:

• neck pain comes with a fever and you cannot bring your chin down to your chest. A stiff neck, fever, severe headache, dislike of light, nausea, drowsiness or confusion, and sometimes a rash that does not fade when a glass is pressed against it — that may be meningitis. It unfolds over hours, so waiting for morning is not an option;
• the neck started hurting after a heavy blow, a road accident, a dive or a fall. Do not lift the person, do not sit them in a car and do not turn their head — call an ambulance and leave them lying down. The same applies to a fall from standing height if the person is elderly, has osteoporosis or takes blood-thinning medicines: in them, things break that would have held in someone young;
• a very severe pain has struck suddenly in the neck or the back of the head, unlike anything before, especially after a sharp turn of the head, a jerk or a manipulation of the neck, and with it there is headache, dizziness, double vision, unsteadiness, slurred speech, numbness of one side of the face or a drooping eyelid. That is how a vertebral artery dissection shows itself — a tear in the inner wall of the artery which can end in a stroke;
• weakness or numbness has come on acutely in the arms and legs at once, objects cannot be held, walking is unsteady, or there is retention of urine, incontinence or numbness around the genitals and back passage;
• the pain spreads to the jaw, arm or chest and comes with breathlessness, cold sweat, nausea or a feeling of pressure behind the breastbone: a heart attack sometimes looks like neck pain too.

What must not wait

See a doctor the same day or within the next few days if:

• weakness, numbness or clumsiness has appeared in the hands, your walking has changed, or passing urine has altered. There is more on this below: that combination means the spinal cord is suffering, not "wear and tear in the neck", and it needs sorting out urgently;
• a fever has joined the neck pain without a cold — particularly after recent surgery, an injection near the spine or an infection with pus, if you take medicines that suppress the immune system, or if you have injected drugs. Spinal infection is rare, but the earlier it is found the better it is treated;
• you have or have had a tumour, and the neck pain is new, constant, wakes you at night and comes with weight loss, sweats or loss of appetite. That is the combination worth being over-cautious about;
• the pain began for no reason after the age of fifty and does not have the usual muscular character;
• the neck started hurting after an injury, even a minor one, and you have osteoporosis, have taken steroids long term or have had radiotherapy to the area;
• weakness in an arm is getting worse day by day;
• the pain keeps you awake several nights running and does not respond to ordinary painkillers;
• along with the pain there are firm enlarged glands in the neck, hoarseness, difficulty swallowing or a lump sensation that will not go;
• a child has a fever together with neck pain, or will not let their head be turned, or holds their head to one side and cannot straighten it;
• pain or stiffness lasts more than a few weeks despite moving and taking painkillers.

Arm and legs: nerve root or spinal cord

This is the central distinction in the whole subject, and it is the one most often missed. Nerve roots leave the neck to supply the arms, and inside the spine runs the spinal cord, on which the arms, the legs and the bladder all depend. Compression of a root and compression of the cord give completely different pictures and call for completely different action.

A compressed nerve root feels like pain shooting from the neck into the shoulder blade and down the arm in a narrow band, sometimes as far as particular fingers. The same strip tingles and goes numb, and occasionally one specific movement weakens. The pain worsens with coughing, sneezing and tipping the head back, and eases if you rest your hand on top of your head. It is unpleasant and at times very painful, but in the great majority of cases it settles on its own over weeks or a few months, and is treated without surgery.

Compression of the spinal cord behaves differently, and it is not recognised by pain — there may be barely any. What to watch is function:

• the hands lose dexterity: buttons will not do up, the key misses the lock, handwriting deteriorates, things get dropped;
• weakness and numbness appear in both arms rather than one;
• walking becomes unsteady, the feet go wider apart, it is noticeably worse in the dark and on uneven ground, and the legs feel either soft or, conversely, stiff;
• passing urine changes: the urge becomes sudden and pressing, you get up at night, there are leaks or, the other way round, difficulty starting;
• a shock-like sensation runs down the spine when the head is bent forwards.

This is not "calcium deposits" and not a reason for a course of massage. Cord compression advances in steps: a person lives for months in a new, slightly worse state, gets used to it, and the next step down arrives abruptly. What has been lost recovers poorly, so the point of treatment is to stop it before it is lost. It needs a neurological examination, magnetic resonance imaging and a neurosurgeon's opinion. And separately: with these symptoms the neck must not be manipulated, traction must not be applied and sudden movements must not be forced — that can settle the matter in one session.

Collars and rest: why they are no longer advised

Neck pain used to earn almost everyone a soft collar and instructions to rest up. When that was compared with carrying on as normal, the result was the opposite of what had been expected: the people who wore a collar and protected the neck took longer to recover and more often ended up with lasting pain.

The reason is plain enough. In a week off duty the neck muscles weaken, the joints stop travelling through their full range, and the mind gets used to the idea that the neck is fragile and moving it is risky. Fear of movement is no small thing: it is precisely what turns a fortnight of pain into several months of it.

So for ordinary neck pain a collar is not needed, and movement is the treatment. Collars remain for situations where a doctor prescribes one: immobilisation immediately after a serious injury until the person has been examined and imaged, the period after surgery, proven instability of the vertebrae. Wearing one "while it hurts", on your own initiative, is not the thing to do.

Exactly the same goes for bed rest. Neck pain does not call for lying down: it is sensible to ease off for a day or two, but not to suspend normal life. Working, walking, driving if the head will turn — all of that is allowed and wanted. The one restriction is obvious: if the neck will not turn far enough for you to see the road, do not drive.

What actually helps

• Keep moving. Turn and tilt the head within what you can tolerate, extending the range a little each day. Pain on moving, within sensible limits, does not mean harm is being done. Ready-made exercise routines are not set out here, and not out of reticence: a programme has to be matched to what is actually hurting you, and that is the job of a physiotherapist.
• Heat or cold, whichever you prefer. A warm shower, a hot water bottle or a warm compress through a cloth for fifteen to twenty minutes relaxes the muscles; in the first twenty-four hours after an injury many people get on better with cold, also through a cloth and never straight onto skin. Neither treats the cause, but they relieve enough to let you move.
• Pain relief. Paracetamol, or a short course of non-steroidal anti-inflammatories by mouth or as a gel on the neck. Agree the choice and the dose with a doctor or pharmacist, particularly if you have stomach, kidney or heart problems, in pregnancy, and if you take other medicines. The point of pain relief here is not to feel nothing, but to be able to move and to sleep.
• The pillow. Look not for an "orthopaedic" one but for a suitable one: the head should rest in line with the spine, without kinking up or down. On your side you need a thicker pillow, on your back a thinner one. Sleeping on your front is the worst option for the neck: the head spends eight hours turned as far as it will go.
• The desk and the phone. Top of the screen at eye level, elbows supported, the phone raised to your face rather than your head lowered to it. But there is no perfect posture, and the main rule is a different one: change position often and get up at least every half hour. The best posture is the next one.
• Sleep and tension. Poor sleep and stress make neck pain appreciably worse: the muscles of the shoulder girdle and the jaw stay tight around the clock, often with clenched teeth at night. That is not something a gel will fix.
• If nothing improves after a few weeks, ask your doctor about physiotherapy: prescribed exercises for mobility and strength in the neck and shoulder girdle are the best-evidenced thing there is for persistent pain.

What not to do: spend weeks lying down, wear a collar on your own decision, demand a scan with every flare-up, agree to forceful manipulation of the neck when the cause of the pain is unclear, or move from one course of injections to the next while nothing changes. If nothing has shifted in six weeks, what needs changing is the approach, not the number of sessions.

How to stop it coming back

Neck pain likes to recur, and what prevents it is not perfect furniture but the habit of moving.

• Regular physical activity of any kind is the most reliable thing known. Exercises for the back and shoulder girdle are particularly worthwhile: the sturdier the frame, the less the neck has to take.
• Break up long stretches of sitting: a short pause every half hour, a walk about, roll the shoulders, look out of the window.
• Do not carry a heavy bag permanently on one shoulder, and do not lift loads with your trunk twisted.
• Sort out your sleep: a consistent bedtime, a pillow that suits you, and not on your front.
• Smoking and excess weight worsen the course of any chronic pain, this one included.
• If the pain returns, do the same as the first time and do not panic. A fresh episode does not mean the neck is falling apart: in most people these flare-ups alternate with quiet spells for years, and each one passes.

Online consultation

Neck pain is a subject where talking genuinely settles a great deal, because almost all the information needed lies in the answers to questions rather than in an examination. The Oladoctor doctor will ask how the pain started, where it spreads, what makes it worse, whether there was an injury, and what is happening with the hands, the walking and passing urine — and from that alone will say whether this is ordinary muscle and joint pain or a picture that needs seeing in person and urgently. They will help choose pain relief in the light of your other conditions and medicines, explain whether imaging is needed right now (usually it is not), which specialist is worth seeing and what physiotherapy actually delivers. And they will say plainly when the conversation has to stop: fever with a stiff neck, a recent injury, growing weakness in the arms and legs or a change in the way you walk are not matters for a remote appointment, they are a reason to go to hospital.

This material is for information only and does not replace medical advice.