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When to Worry About Neck Pain…and when not to!

Tips, checklists, and non-scary possible explanations for neck pain

updated (first published 2016)
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com
Photo of woman holding her neck, with graphics of red starburst indicating neck pain.

We fear spine pain more than we fear other kinds of pain. Backs and necks seem vulnerable. And yet most spinal pain does not have a serious cause. The bark of neck pain is usually worse than its bite. This article explains how to tell the difference. If you’ve been getting worried, this is a good place to get some reassurance.

Red flags for serious causes of neck pain

Although it’s rare, once in a while neck pain may be a warning sign of cancer, infection, autoimmune disease, or some kind of structural problem like spinal cord injury or a threat to an important blood vessel. Fortunately, most of these ominous situations cause hard-to-miss signs and symptoms other than pain and are likely to be diagnosed correctly and promptly. If you are aware of the “red flags,” you can get checked out when the time is right — but avoid excessive worry before that.

The rule of thumb is that you should start a more thorough medical investigation only when all three of these conditions are met, three general red flags for neck pain:

  1. it’s been bothering you for more than about 6 weeks
  2. it’s severe and/or not improving, or actually getting worse
  3. there is at least one other “red flag” (see below)

And there is one (hopefully obvious) situation where there’s no need to wait several weeks before deciding the situation is serious: if you’ve had an accident with forces that may have been sufficient to fracture your spine or tear nerves. I didn’t really have to tell you that, did I? Well, I did for legal reasons! 😃

Want more? PainScience.com has a complete guide to neck pain, especially the kind of neck pain that feels like something is stuck — neck cricks. This article is an excerpt.

Several more specific red flags for neck pain: a checklist

Check all that apply. Most people will not be able to check many of these! But the more you can check, the more worthwhile it is to ask your doctor if it’s possible that there’s something more serious going on than just neck pain. Most people who check off an item or two will turn out not to have an ominous health issue. But red flags are reasons to check… not reasons to worry.

Signs of arthritis are not red flags

One of the most common concerns about the neck that is not especially worrisome: signs of “wear and tear” on the cervical spine, arthritis, and degenerative disc disease, as revealed by x-ray, CT scans, and MRI. Many people who have clear signs of arthritic degeneration in their spines will never have any symptoms, or only minor, and/or not for a long time.10 For instance, about 50% of fortysomethings have clinically silent disk bulges, and even at age 20 there’s a surprising amount of spinal arthritis. The seriousness of these signs is routinely overestimated by patients and healthcare professionals alike.11

Signs of arthritis are almost never diagnostic on their own.12 Do yourself a favour: don’t assume that you have a serious problem based only on pain plus signs of arthritis. Pain is common; serious degeneration is not.

Percentages of people with various kinds of spinal degeneration but no pain. Source: Brinjikji et al
Imaging finding Age
20 30 40 50 60 70 80
Disc degeneration 37% 52% 68% 80% 88% 93% 96%
Disk height loss 24% 34% 45% 56% 67% 76% 84%
Disk bulge 30% 40% 50% 60% 69% 77% 84%
Disk portrusion 29% 31% 33% 36% 38% 40% 43%
Annular fissure 19% 20% 22% 23% 25% 27% 29%
Facet degeneration 4% 9% 18% 32% 50% 69% 83%

Sharp, stabbing, and shooting neck pains are usually false alarms

Sharp neck pain is not in itself a red flag. Believe it or not there is no common worrisome cause of neck pain that is indicated by a sharp quality. In fact, oddly, sharp pains are actually a bit reassuring, despite how they feel. In isolation — with no other obvious problem — they usually indicate that you just have a temporary, minor source of irritation in the cervical spine. Serious causes of neck pain like infections, tumours, and spinal cord problems tend grind you down with throbbing pains, not “stab” you.

Sharp, shooting pains are mostly neurological false alarms about relatively trivial musculoskeletal troubles: your brain reacting over-protectively to real-but-trivial irritations in and around the spine. The brain takes these much more seriously than it really needs to, but evolution has honed us to be oversensitive in this way. That’s not to say that the brain is always over-reacting, but it usually is. Most of the time, a sharp pain is a warning you can ignore.

The cervical spine is also surrounded by a thick, tangled web of nerves. In general, those nerves are amazingly difficult to irritate, much harder than people think, but it’s not impossible. Many sharp and shooting neck pains are probably caused by minor neuropathy (pain from nerve irritation) that will ease gradually over several days or a few weeks at the worst, like a bruise healing. It’s unpleasant, but not actually scary, like banging your funny bone (ulnar nerve): that thing can really take a licking and keep on ticking. So can the nerves in your neck.

Is a stiff neck serious?

Rarely. Nearly all neck stiffness is minor, diffuse musculoskeletal pain: several mildly irritated structures adding up to uncomfortable, reluctant movement. The most common scary neck stiffness is the “nuchal rigidity” of meningitis — which makes it very difficult and uncomfortable to tilt the head forward — but that will be accompanied by other serious warning signs, of course. Like feeling gross otherwise (flu-like malaise).

If you have severe neck stiffness for a long time, plus any other warning signs, there could be a worrisome cause — but still probably not, and probably not urgent. Investigate if you have enough red flags, and even then it’s likely to amount to nothing.

Miscellaneous medical causes of neck pain that might mean you can stop worrying about something worse

This section presents a comprehensive list of somewhat common medical problems that can cause neck pain (and might, conceivably, be confused with an “ordinary” case of neck pain). I’ll give you a quick idea of what they are and what distinguishes them. If you find anything on this list that seems awfully similar to your case, please bring the idea to your doctor like a dog with an interesting bone; and get a referral to a specialist if necessary.

Important! None of these are dangerous! Although some are quite unpleasant. Reading about medical problems on the Internet can easily freak us out,13 so the goal here is to identify possible causes of neck pain that are not so scary. If you can get a positive ID on one of these conditions, then you get to stop worrying about the threat of something worse.

Some skin problems on the neck can cause neck pain, but are usually obvious — most people will identify them as “skin problems on the neck” and not “a neck problem affecting the skin.” Herpes zoster (shingles) [CDC] causes a painful rash, cellulitis [Mayo] is extremely painful but superficial, and a carbuncle[Wikipedia] … well, it’s just a super zit, basically. If you can’t diagnose that one on your own, I can’t help you!

Bornholm disease [NHS] is a crazy viral disease with several other intimidating names.14 It feels like a vice-grip on the chest and lungs, is intensely painful, and sometimes also causes neck pain. If you feel like you can’t breathe, you should look into this. The infection is temporary. It’s an extremely unlikely diagnosis.

Trichinosis [Wikipedia] (or trichinellosis, or trichiniasis) is a parasitic disease caused by eating raw or undercooked pork and wild game. It can be mild or severe or fatal, and digestive disturbance is likely. It can also cause spasming and widespread muscle pain, including the neck. There’s a laundry list of other symptoms.

Photo of a person’s temple, with an obvious swollen and tortuous artery.

Temporal arteritis can cause neck pain as well as fierce headaches.

Temporal arteritis [healthline] is an inflammation of arteries in the temple, with a lot of symptoms: severe headache, fever, scalp tenderness, jaw pain, vision trouble, and ringing in the ears are all possible symptoms, along with neck pain. It’s almost unheard of in people younger than 50, and it usually occurs in people with other diseases or infections.

Lymphadenopathy. [Merck] The lymph nodes of the neck may bulge and swell in response to disease or infection. Once in a blue moon, someone might mistake these bulgings for muscle knots. More likely, it will be obvious that something else is going on: a variety of other symptoms.

Parsonage-Turner syndrome, [RareDiseases.org] inflammation of the brachial plexus. For no known reason, sometimes the web of nerves that exit the cervical spine, the brachial plexus, becomes rapidly inflamed. This condition may sometimes occur along with neck pain. Strong pain in the shoulder and arm develops quickly, weakens the limb, and even atrophies the muscles over several months. There is no cure, but most people make a complete recovery.

Thyroiditis, [Wikipedia] inflammation of the thyroid gland in the throat, can be difficult to diagnose, causing a bewildering array of vague symptoms. If your neck pain is accompanied by symptoms like fatigue, weight gain, feeling “fuzzy headed,” depression and constipation, consider checking with your doctor.

Eagle’s syndrome [Medscape] is a rare abnormal elongation of a bizarre little bit of bone at the back of the throat called the styloid process. Even a normal styloid process looks jarring when you first see one: it is so skinny and sharp that it makes one wonder how it can possibly not be stabbing something. Well, it turns out that in some cases it does “stab” you in the neck. This will cause a feeling of a lump in the throat and/or moderate intensity pains throughout the region, possibly including the side of the neck, although pain is more likely to dominate the jaw and throat.15

And one more important one…

Necks just hurt sometimes

The neck is one of a few areas of the body — along with the low back, jaw, and bowels — that is vulnerable to bouts of unexplained pain, sometimes quite stubborn. In most cases, the pain goes away. Pain is weird and unpredictable, and is often the result of the brain being overprotective and paranoid.

Worrying about the pain may be literally the worst thing you can do — not just a poor coping mechanism, but a genuine risk factor. Like noise pollution, the more you focus on it, the worse it gets. That’s why this article is focused on rational reassurance.

If you want more, carry on with my huge neck crick tutorial, for people with a frustrating sensation of mechanical stuckness. Or read about the weirdness of pain and learn more about how to tame your brain’s false alarm: Pain is Weird.


About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

Related Reading

What’s new in this article?

Five updates have been logged for this article since publication (2016). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more Like good footnotes, update logging sets PainScience.com apart from most other health websites and blogs. It’s fine print, but important fine print, in the same spirit of transparency as the editing history available for Wikipedia pages.

I log any change to articles that might be of interest to a keen reader. Complete update logging started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.

See the What’s New? page for updates to all recent site updates.

Although this content has been around for ages in my neck pain tutorial, I first excerpted it and published as a separate article Jul 2, 2016.

SeptemberNew section: “Signs of arthritis are not red flags.”

AprilAdded important red flag information about artery tears with pain as the only symptom.

JanuarySeveral good red flag clarifications and a couple interesting new references about spinal cord compression. Also added three new sections: “Necks just hurt sometimes,” “Sharp, stabbing, and shooting neck pains are usually false alarms,” and “Is a stiff neck serious?” Miscellaneous editing.

2016Revised intro, clarified a couple points, added a several links to authoritative sources of information on other conditions that can affect the neck.

2016Added a couple images, some links. Minor editing.

2016Publication.

Notes

  1. Thunderclap headaches have many possible causes, several dozen of them (see Devenney et al). Most are benign, but many are frightening and even deadly, and there’s no way to tell the difference without expert help. If you are having sudden, severe headaches, please see your doctor. BACK TO TEXT
  2. Arnold M, Cumurciuc R, Stapf C, et al. Pain as the only symptom of cervical artery dissection. J Neurol Neurosurg Psychiatry. 2006 Sep;77(9):1021–4. PubMed #16820416. PainSci #53624.

    A study of 245 patients with spontaneous cervical artery dissection found that 20 (8%) of them suffered just one symptom — distinctive pain — even in five who had multiple dissections. It took about a week to diagnose most of them. Only two had neck pain alone, and six had headache alone; twelve had both.

    BACK TO TEXT
  3. Kerry R, Taylor AJ. Cervical arterial dysfunction: knowledge and reasoning for manual physical therapists. J Orthop Sports Phys Ther. 2009 May;39(5):378–87. PubMed #19411768.

    A discussion of the clinical challenge of cervical artery dissection that presents with pain as the only symptom.

    BACK TO TEXT
  4. Maruyama H, Nagoya H, Kato Y, et al. Spontaneous cervicocephalic arterial dissection with headache and neck pain as the only symptom. J Headache Pain. 2012 Apr;13(3):247–53. PubMed #22350749. PainSci #53625.

    A small study of just 7 patients with pain as the only symptom of spontaneous cervical artery dissection. There was disconcerting variety in presentation, but the pain was consistently severe, unfamiliar, unilateral, and mostly sudden onset. “Cervicocephalic arterial dissection should be suspected when patients complain of intense unilateral posterior cervical and occipital pain or temporal pain.”

    BACK TO TEXT
  5. Arnold “Pain topography, dynamics, quality and intensity were heterogeneous.” In other words, there are almost certainly some cases that are effectively impossible to distinguish from ordinary neck pain and headache. BACK TO TEXT
  6. Maruyama et al: “All but one patient [of seven] with migraine considered the pain to be unique and unusual compared with previously experienced headache or neck pain episodes. Nevertheless, pain was often interpreted initially as migraine or musculoskeletal in nature by the patient or the treating doctor.” Arnold et al: “Pain was different from earlier episodes in all but one case [of 20].” BACK TO TEXT
  7. Remember the F.A.S.T. signs of stroke: face drooping, arm weakness, speech difficulty… time to call 911! Non-stroke (or pre-stroke) symptoms associated with artery tears: neck swelling, reduced vision and/or visual disturbance, constricted pupil, drooping eyelid, pulsatile ringing in the ears, decreased taste. BACK TO TEXT
  8. Symptoms caused by spinal cord trouble are called “myelopathy.” And there are a lot of possible symptoms: it depends on which part of the spinal cord is affected. And many of them can have other causes. And it may worsen slowly and erratically over long periods. You can’t really confirm a myelopathy diagnosis without professional help, so please consult a doctor if you’re suspicious. BACK TO TEXT
  9. But “unwell” is awfully vague and can have many causes — only consider it a red flag if it’s quite clear and has developed in roughly the same period as the neck pain. BACK TO TEXT
  10. In 2015, Brinjikji et al found that 37% of 20-year-olds had disc degeneration without symptoms, and a whopping 96% of 80-year-olds did — so almost everyone! The stats were similar for other degenerative signs like disk bulges and annular fissures (“aging cracks”), all extremely common in people with no pain at all:

    Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.

    BACK TO TEXT
  11. Health professionals may know better in theory, but often underestimate how easily patients are alarmed by hard evidence of spinal degeneration. To the average person, if something like that shows up on a scan, it’s like proof: it has got to hurt. But the evidence clearly contradicts that! Pain has many possible minor causes; degeneration is often painless and rarely serious even when it is causing trouble. BACK TO TEXT
  12. They are mostly good for corroborating what is already obviously a serious problem — for instance, if you already have other red flags and ominous symptoms and there are MRI findings of degeneration that might explain those symptoms. But of course in such case you will already know that you have a big problem! The scan is just clarifying why. Maybe. BACK TO TEXT
  13. NewYorker.com [Internet]. Cook G. The Nocebo Effect: How We Worry Ourselves Sick; 2015 May 13 [cited 15 May 13].

    Placebo is belief-powered relief from symptoms, while nocebo is belief-powered symptoms, or “the placebo effect’s malevolent Mr. Hyde.” And: “The Internet has become a powerful…nocebo dosing machine.” Agreed: nocebo is a genuine hazard when writing about medical problems.

    BACK TO TEXT
  14. AKA epidemic pleurodynia or epidemic myalgia or any of several other interesting and colorful names such as Bamble disease, the Devil’s Grip, and The Grasp of the Phantom! I swear I’m not making these up! BACK TO TEXT
  15. Casale M, Rinaldi V, Quattrocchi C, et al. Atypical chronic head and neck pain: don't forget Eagle's syndrome. Eur Rev Med Pharmacol Sci. 2008;12(2):131–3. PubMed #18575165. BACK TO TEXT