What causes a stiff neck

Stiff neck and painful neck is a common condition that will affect most people at some point in their lives. When your neck is sore, you may have difficulty moving it, especially turning to one side. Many people describe this as having a stiff neck. Many different things can cause a stiff neck, which is usually not the sign of a more serious condition. The neck pain can be due to any of the structures in the neck, including the muscles, nerves, bones (vertebrae), joints, and the discs between the bones. The pain often spreads from the neck towards the shoulders or upper back, and it often causes headaches.

If you’ve woken up with a stiff and painful neck, that’s twisted to one side, you may have torticollis ¹. When the symptoms of a twisted (or wry) neck appear suddenly (such as overnight), it is called acute torticollis.

Torticollis usually causes pain on one side of your neck but you may feel pain in the middle of the neck and in the shoulders and head. Your neck may be very tender and if you try to massage the area, to provide some relief, it’s possible your neck muscles will spasm. You may also find it difficult to straighten your neck or turn your head a particular way.

Symptoms of a twisted neck will usually disappear completely within a week, and they usually ease considerably within one or two days. Sometimes symptoms last longer, but this is not common.

Torticollis is the most common cause of neck pain in young people and it’s not generally associated with a previous neck injury or neck pain.

Common Causes of Stiff Neck

Common causes of neck pain include:

• sitting or sleeping in an awkward position, without sufficient support for your head
• poor posture, such as at a workstation that is not ergonomically suited to you
• poor posture (the way your body is positioned when standing or sitting) e.g. bending over a desk for hours
• having poor posture while watching TV or reading
• having your computer monitor positioned too high or too low
• carrying bags with unequal amounts of weight that cause your neck to strain, for example, a handbag on one side and heavy shopping bags on the other
• lifting things too quickly or with poor posture
• sleeping or sitting in a draughty room, where the neck is exposed to the cold.
• tension
• injury such as a muscle strain or sprains
• prolonged use of a desktop or laptop computer
• cervical arthritis or spondylosis
• wear and tear in the bones of the neck, which is a normal part of ageing.

Rare causes of neck pain include:

• damage to the vertebrae, spinal cord or nerves in the neck
• cancer
• meningitis
• fibromyalgia
• ruptured disk
• small fractures to the spine from osteoporosis
• spinal stenosis (narrowing of the spinal canal)
• infection of the spine (osteomyelitis, discitis, abscess).

Preventing neck pain

If you’ve had trouble with neck pain in the past, there are ways of preventing further problems.

One of the most important things you can do is to maintain good posture. Keeping your head centred over your spine helps reduce much of the strain on your neck muscles. People who work long hours driving, sitting at a desk or hunching over a workbench often suffer from neck pain due to their posture.

Make sure you follow advice for ergonomic workstation comfort and safety. Try the following:

• make sure you take regular breaks and take the time to stretch your back and neck muscles;
• if you are working on a computer, make sure that the top of the monitor is at eye level;
• don’t leave your arms unsupported;
• sit with your knees slightly lower than your hips; and
• avoid clenching your teeth.

Posture-correcting exercise processes that re-educate the body, such as pilates, can also help prevent neck pain, as can yoga and tai chi.

You can also help prevent neck pain by using a supportive neck pillow and sleeping on a firm mattress.

Relaxation techniques and regular exercise are also important in preventing stress and tension in the neck muscles. Maintaining general fitness helps prevent further exacerbations of neck pain by improving muscle tone and posture.

You should see a doctor if:

Seek medical help right away if you have:

• A fever and headache, and your neck is so stiff that you cannot touch your chin to your chest. This may be meningitis. Call your local emergency number or get to a hospital.
• symptoms of a heart attack, such as shortness of breath, sweating, nausea, vomiting, or arm or jaw pain.
• the pain is getting worse and your pain does not go away with regular doses of over-the-counter pain medicine
• the pain doesn’t ease up in a week or so
• you have numbness, tingling or pins and needles in your arms or legs
• you start having difficulties with your bladder or bowel you have a fever as well as neck pain.
• you lose control over urination or bowel movements
• you have a fever as well as neck pain.
• you have numbness, tingling, or weakness in your arm or hand
• your neck pain was caused by a fall, blow, or injury — if you cannot move your arm or hand, have someone call your local emergency number
• you have swollen glands or a lump in your neck
• you have difficulty swallowing or breathing along with the neck pain
• the pain gets worse when you lie down or wakes you up at night
• your pain is so severe that you cannot get comfortable
• you have trouble walking and balancing.

How to get rid of a stiff neck

Currently there is no cure for neck pain, but there are many things that can help.

If you have stiff neck (twisted, torticollis) you can do a number of things to help manage the condition. Some of these measures include:

• Keep active and move your neck as normally as possible, even if it is very painful. You should try not to make sudden movements for a day or so, but then you try to carry on with your normal routines and move your head and neck to prevent it stiffening up.
• Hold an ice pack or a bag of frozen peas on your neck for 15-20 minutes three or more times a day.
• Have a hot shower or a warm bath.
• Exercise your neck muscles gently, as suggested below.
• Try gently moving your neck in circles and moving it backwards, forwards and to either side to loosen the muscles and keep your neck supple.
• Get advice on suitable pain relief medicines. Your doctor may recommend medication such as: paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs). Sometimes stronger pain relievers (such as codeine) are used for a limited time if neck pain is interfering with the ability to carry out usual activities.
• Apply heat with a heat pad, which may relieve neck stiffness and pain.
• Have a massage.
• You may find some physical therapies such as physiotherapy, chiropractic, osteopathy, acupuncture, massage of use.
• Hold reading materials at eye level to avoid hunching over.
• Ensure your working environment is adjusted to your needs. You may need a footstool to ensure your hips and knees are level. Ask for a telephone headset if you spend a lot of time on the phone to avoid bending your neck to one side constantly. You may also need to adjust the height of your computer screen to avoid stretching your neck.
• Work on your posture – exercises such as those found in yoga or Pilates all work to improve your posture.
• Try sleeping with one firm support pillow rather than softer pillows to avoid stretching your neck muscles.

Neck supports (braces and collars) are not generally recommended, unless your healthcare professional has advised you to wear one.

Avoid activities such as lifting, pulling, punching, and repetitive bending and twisting for a few days as they can make your neck pain worse.

If you cannot fully move your neck left and right, you should not drive until you have regained full movement in your neck. If you can safely drive, adjust your headrest so that your head and neck are properly supported.

Medicines can also help with your back pain.

For minor, common causes of neck pain:

• Take over-the-counter pain relievers such as ibuprofen (Advil, Motrin IB) or acetaminophen (Tylenol).
• Apply heat or ice to the painful area. Use ice for the first 48 to 72 hours, and then use heat after that.
• Apply heat with warm showers, hot compresses, or a heating pad. To prevent injury to your skin, DO NOT fall asleep with a heating pad or ice bag in place.
• Stop normal physical activity for the first few days. This helps calm your symptoms and reduce inflammation.
• Do slow range-of-motion exercises, up and down, side to side, and from ear to ear. This helps gently stretch the neck muscles.
• Have a partner gently massage the sore or painful areas.
• Try sleeping on a firm mattress with a pillow that supports your neck. You may want to get a special neck pillow.
• Ask your health care provider about using a soft neck collar to relieve discomfort. However, using collar for a long time can weaken neck muscles. Take it off from time to time to allow the muscles to get stronger.

OVER-THE-COUNTER PAIN RELIEVERS

Over-the-counter means you can buy them without a prescription.

Most health care providers recommend acetaminophen (such as Tylenol) first because it has fewer side effects than other drugs. Do not take more than 3 grams (3,000 mg) on any one day, or over 24 hours. Overdosing on acetaminophen can cause severe damage to your liver. If you already have liver disease, ask your doctor if acetaminophen is OK for you to take.

If your pain continues, your provider may suggest nonsteroidal anti-inflammatory drugs (NSAIDs). You can buy some NSAIDs, such as ibuprofen and naproxen, without a prescription. NSAIDs help reduce the swelling around the swollen disk or arthritis in the back.

NSAIDs and acetaminophen in high doses, or if taken for a long time, can cause serious side effects. Side effects include stomach pain, ulcers or bleeding, and kidney damage. If side effects occur, stop taking the drug right away and tell your provider.

If you are taking pain relievers for more than a week, tell your provider. You may need to be watched for side effects.

NARCOTIC PAIN RELIEVERS

Narcotics, also called opioid pain relievers, are used only for pain that is severe and is not helped by other types of painkillers. They work well for short-term relief. Do not use them for more than 3 to 4 weeks unless instructed by your provider to do so.

Narcotics work by binding to receptors in the brain, which blocks the feeling of pain. These drugs can be abused and are habit-forming. They have been associated with accidental overdose and death. When used carefully and under a provider’s direct care, they can be effective in reducing pain.

Examples of narcotics include:

• Codeine
• Fentanyl — available as a patch
• Hydrocodone
• Hydromorphone
• Morphine
• Oxycodone
• Tramadol

Possible side effects of these drugs include:

• Drowsiness
• Impaired judgment
• Nausea or vomiting
• Constipation
• Itching
• Slowed breathing
• Addiction

When taking narcotics, do not drink alcohol, drive, or operate heavy machinery.

MUSCLE RELAXANTS

There is currently no evidence that muscle relaxants (including benzodiazepines) are effective in the treatment of short-term neck pain. These medicines are associated with significant side effects and can cause dependency. However, your provider may still prescribe a muscle relaxant.

This drug is often given along with over-the-counter pain relievers to relieve the symptoms of neck pain or muscle spasm.

Examples of muscle relaxants include:

• Carisoprodol
• Cyclobenzaprine
• Diazepam
• Methocarbamol

Side effects of muscle relaxants are common and include drowsiness, confusion, nausea, and vomiting.

These medicines can be habit-forming. Talk to your provider before using these drugs. They may interact with other medicines or make certain medical conditions worse.

Do not drive or operate heavy machinery while taking muscle relaxants. Do not drink alcohol while taking these drugs.

ANTIDEPRESSANTS

Antidepressants are normally used to treat people with depression. But, low doses of these medicines can help with chronic low back pain, even if the person does not feel sad or depressed.

Certain antidepressants (the so-called tricyclic antidepressants) have been found to relieve certain types of pain, and can be prescribed to help control neck pain that is not responding to regular pain relievers. These medicines may also relieve pain that is worse at night, and pain that is caused by compression or damage to a nerve root in the neck.

These drugs work by changing the levels of certain chemicals in your brain. This changes the way your brain notices pain. Antidepressants most commonly used for chronic low back pain also help you sleep.

Antidepressants most often used for back pain are:

• Amitriptyline
• Desipramine
• Duloxetine
• Imipramine
• Nortriptyline

Common side effects include dry mouth, constipation, blurred vision, weight gain, sleepiness, problems urinating, and sexual problems. Less commonly, some of these drugs can also cause heart and lung problems.

Do not take these drugs unless you are under the care of a provider. Do not stop taking these drugs suddenly or change the dose without also talking with your provider.

ANTI-SEIZURE OR ANTICONVULSANT MEDICINES

Anticonvulsant medicines are used to treat people with seizures or epilepsy. They work by causing changes in the electric signals in the brain. They work best for pain that is caused by nerve damage.

These drugs may help some people whose long-term back pain has made it hard for them to work, or pain that interferes with their daily activities. They can also help relieve radiating pain that is common with back problems.

Anticonvulsants most often used to treat chronic pain are:

• Carbamazepine
• Gabapentin
• Lamotrigine
• Pregabalin
• Valproic acid

Common side effects include weight gain or weight loss, upset stomach, loss of appetite, skin rashes, drowsiness or feeling confused, and headaches.

Do not take these drugs unless you are under a provider’s care. Do not stop taking these drugs suddenly or change the dose without also talking with your provider.

Physiotherapy

Physiotherapists can help treat your neck pain with a variety of treatments, including:

• massage;
• ultrasound (which can reduce muscle and joint pain);
• transcutaneous electrical nerve stimulation – TENS (a therapy that uses mild electrical currents to treat pain);
• mobilisation (a manual treatment that can improve joint function as well as stretch tight muscles and ligaments); and
• traction (which involves creating a sustained pull on the neck, and can bring fast relief for some people with neck pain, especially if the pain is related to nerve root irritation or muscle spasms).

Manipulation

Spinal manipulation (usually performed by osteopaths or physiotherapists) is another treatment option for certain neck conditions. The therapist uses their hands to adjust the joints in your neck with the aim of relieving pain and stiffness. Manipulation is not suitable for some people, and there is a small risk of serious side effects, including neck injuries and even stroke, so check with your doctor before receiving this treatment.

Neck exercises

There are some simple exercises you can do to help strengthen the muscles in your neck and keep your neck mobile.

Try gently nodding 15 times. Bring your chin down to your chest as far as is comfortable, and up towards the ceiling as far as is comfortable.

Turn your head slowly from left to right 15 times. You should only turn your head as far as feels comfortable.

Tilt your head as if you are trying to touch your left shoulder with your left ear, and the same for the right 15 times. Again, only tilt your head as far as is comfortable for you. Don’t move your shoulders up to meet your ears.

Cervical flexion

Increasing neck movement by moving the head forwards in sitting.

Cervical side-flexion

Active neck movement bending side to side (side-flexion) in sitting position

Cervical rotation

Active neck movement by turning side to side (rotation) in sitting position.

Chin tucks (cervical retraction)

Strengthening of the stabilising neck muscles by drawing the chin in gently in sitting position.

Figure 1. Neck exercises for neck pain including pinched nerve in the neck

[Source ²]

And to reduce your chances of future episodes of neck pain, you can:

• Improve your posture with gentle stretching exercises, such as those popular in activities such as yoga or Pilates.
• Arrange your work space so that your desk and chair are suitable for your needs. Ask for a footrest if you find that your knees and hips are not level and your feet do not sit flat on the ground. You may also need to move items that you use regularly closer to you, so that you don’t twist or reach too far to find items you need.
• Support your neck while sleeping with a support pillow, and sleep with just one pillow.
• Make sure your neck is supported in the car by adjusting the headrest so that it is at least at eye level and as close to the back of your head as possible.

Acupuncture

Another treatment that may provide relief from neck pain is acupuncture, which involves having small needles inserted into specific areas called acupuncture points just below the surface of the skin. While many people report that acupuncture improves their pain, there is currently no evidence from clinical trials to either prove or disprove its effectiveness as a treatment for neck pain.

Other therapies

Stress management and relaxation techniques are also useful, as they can help relieve chronic muscle tension that may be contributing to neck pain.

Some doctors recommend psychological treatments such as cognitive behavioural therapy (CBT) for ongoing problems with neck pain. CBT can help you gain a sense of control over your pain and help you manage it more effectively.

You should see a doctor if:

Seek medical help right away if you have:

• A fever and headache, and your neck is so stiff that you cannot touch your chin to your chest. This may be meningitis. Call your local emergency number or get to a hospital.
• symptoms of a heart attack, such as shortness of breath, sweating, nausea, vomiting, or arm or jaw pain.
• the pain is getting worse and your pain does not go away with regular doses of over-the-counter pain medicine
• the pain doesn’t ease up in a week or so
• you have numbness, tingling or pins and needles in your arms or legs
• you start having difficulties with your bladder or bowel you have a fever as well as neck pain.
• you lose control over urination or bowel movements
• you have a fever as well as neck pain.
• you have numbness, tingling, or weakness in your arm or hand
• your neck pain was caused by a fall, blow, or injury — if you cannot move your arm or hand, have someone call your local emergency number
• you have swollen glands or a lump in your neck
• you have difficulty swallowing or breathing along with the neck pain
• the pain gets worse when you lie down or wakes you up at night
• your pain is so severe that you cannot get comfortable
• you have trouble walking and balancing

Additional treatments for severe neck pain

Corticosteroids

Corticosteroids reduce inflammation and may be used to relieve neck pain in some cases. Corticosteroid medicines can be given by corticosteroid injection into the joints and muscles in the neck, the epidural space (the space between the outer covering of the spinal cord and the vertebrae), or the space around nerve roots.

When given as an injection, corticosteroids are often mixed with a local anaesthetic, and can be used to treat neck pain resulting from:

• inflamed and painful facet joints in the neck (the joints between the vertebrae);
• trigger points (hard, knot-like areas in muscles that are painful to touch and result from repetitive stress on the muscles);
• cervical nerve root irritation — where disc fragments or bone spurs are impinging on a spinal nerve root as it exits the spine; and
• herniated (or slipped) discs.

Surgery for neck pain

Surgery is rarely needed for pain alone, and in most cases is usually performed only after non-surgical therapies have been tried. However, if you have spinal cord compression, surgery is generally required sooner rather than later. Spinal surgery is of benefit only for pain involving nerves — it does not help pain from spondylosis or soft tissue pain.

References

1. Torticollis. https://www.healthdirect.gov.au/torticollis
2. Neck pain exercises. http://www.csp.org.uk/publications/neck-pain-exercises