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

Red flags versus non-scary possible explanations for bad neck pain

Paul Ingraham • Nov 3, 2021 • 20m read

We fear spine pain more than we fear other kinds of pain, especially when it’s severe and/or constant. 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 as well as possible when you’re first starting to wonder just what’s going on in there.

Please do seek care immediately if you’ve been in an accident or you have severe or weird pain or other symptoms — obviously. This article is for non-emergencies. But if you have neck pain that’s been starting to worry you, this is a good place to get some reassurance and decide whether or not to talk to a doctor.

Red flags for serious causes of neck pain

It’s rare, but of course 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. Some of these ominous situations cause hard-to-miss signs and symptoms other than pain and most are likely to be diagnosed correctly and promptly — so, if it feels serious, stop consulting Dr. Google and just go get checked out.

Otherwise, if you are aware of the “red flags,” you can get checked out when the time is right — and avoid excessive worry until then.

The rule of thumb is that you should start a more thorough medical investigation 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? Actually I did — for legal reasons! 😃

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, let alone all of them. But the more you can check, the more worthwhile it is to ask your doctor for some input. 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.

• Light tapping on the spine is painful.
• Weight loss without dieting is a potential sign of cancer.
• Mystery fevers and/or chills (especially in diabetic patients).
• A fierce headache, and/or an inability to bend the head forward (nuchal rigidity), and/or fever, and/or altered mental state are all symptoms of meningitis (inflammation of the membranes covering the brain and spinal cord, caused by infection or drug side effects).
• Facial numbness is often a sign of a dangerous cancer or infection. It’s a rare symptom to see with neck pain, but must be taken seriously when it occurs.1
• A severe headache that comes on suddenly is colourfully called a “thunderclap headache”! Most are harmless, but they should always be investigated.2
• Severe, novel pain (throbbing or constrictive) may be caused by an artery tear345 with a high risk of a stroke. Pain is the only symptom of some tears. Most but not all cases6 are sudden, on one side, and cause both neck and head pain (in the temple or back the skull), but the pain is usually strange.7 Any hint of other symptoms?8 Go to the ER.
• There are many possible signs of spinal cord trouble in the neck,9 with or without neck pain, mostly affecting the limbs in surprisingly vague ways that can have other causes: poor hand coordination; weakness, “heavy” feelings, and atrophy; diffuse numbness; shooting pains in the limbs (especially when bending the head forward); an awkward gait. Sometimes people have both neck pain and more remote symptoms without realizing they are related.
• Unexplained episodes of dizziness and/or nausea and vomiting may indicate a problem with stability of the upper cervical spine. (Such symptoms should never be dismissed by alternative health professionals as “detoxification” or “healing crisis.” For context, see What Happened To My Barber?)
• Steroid use, other drug abuse, and HIV are all risk factors for a serious cause of neck pain.
• If you are feeling quite unwell in any other way, that could be an indication that neck pain isn’t the only thing going on.10
• The main signs that neck pain might be caused by autoimmune disease specifically include: a family history of autoimmune disease, gradual but progressive increase in symptoms before the age of 40, marked morning stiffness, pain in other joints as well as the low back, rashes, difficult digestion, irritated eyes, and discharge from the urethra.

Is right or left neck pain significant?

It’s surprising how often folks find this article because they are searching for information on “neck pain left side” or — oddly much less often — “neck pain right side.” People wonder if the side their pain is clinically significant.

It’s not.

Average neck anatomy is almost perfectly symmetrical.11 There are, of course, many individual anatomical variations, so anyone could have an asymmetric neck — but those are unpredictable quirks that don’t help diagnose anything. In many cases, we don’t even have any way of knowing they exist at all.

And of course something can go wrong on one side and not the other even when you are perfectly symmetrical.

But you could tell the world’s greatest neck pain diagnostician which side your pain is on, and that wouldn’t get her any closer to the answer. Revealing the side of the pain wouldn’t give Dr. Gregory House a diagnostic “a-ha!” moment.

Please don’t worry about the side of your pain — it’s not an important detail.

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.12 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.13

Signs of arthritis are almost never diagnostic on their own.14 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.

Is neck pain a symptom of COVID-19? (Or other common infections?)

All common aches and pains are more likely to be triggered or aggravated by any infection, but perhaps COVID-19 more than most — simply because it’s unusually good at causing widespread body aching, and necks are included in that. But neck pain doesn’t stand out any more than any other common locations for aching or soreness (with the exception of headache, which stands out in 8–14% of cases.1516).

Infamously, meningitis causes severe neck pain and stiffness. That is not a prominent feature of COVID-19 so far, or of any other infection, because infections always lower our pain thresholds.17 If you were already at risk of a flare-up of neck pain, it could emerge during any infection, exposed like a rock that is only visible at low tide. Some COVID patients have worse neck pain than others, but it’s likely that says more about their vulnerability to neck pain than it does about COVID-19. In other words, influenza might cause the same flare-up of neck pain.

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 to 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 as opposed to physically limited 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,18 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) 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.19 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.

Temporal arteritis 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.20

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 alarms.

Did you find this article useful? Interesting? Maybe notice how there’s not much content like this on the internet? That’s because it’s crazy hard to make it pay. Please support (very) independent science journalism with a donation. See the donation page for more information & options.

About Paul Ingraham

I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:

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Other reading on PainScience.com about neck pain

• When to Worry About Low Back Pain — And when not to! What’s bark and what’s bite? Checklists and red flags for the scary causes of back pain
• The Complete Guide to Chronic Tension Headaches — A detailed, science-based tour of stubborn headache diagnosis and treatment, for both patients and professionals
• A Recipe for Chronic Neck Pain After Whiplash — Researchers discover some surprising risk factors for chronic neck pain in the aftermath of whiplash
• What Happened To My Barber? — Either atlantoaxial instability or vertebrobasilar insufficiency causes severe dizziness and vomiting after massage therapy, with lessons for health care consumers
• Neck Pain, Submerged! — The story of my curious experiment with dunking severe chronic neck pain
• Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain — Perfect Spot No. 4, an area of common trigger points in the odd scalene muscle group in the neck

And the big one…

• The Complete Guide to Neck Pain & Cricks — One-stop information shopping: an extremely detailed guide to the myths, controversies, the nature of the beast and — the highlight — dozens of detailed, evidence-based reviews of treatment and therapy options. This huge tutorial also focusses on something that’s very hard to find information on: the frustrating sensation of a “crick.”

Notes

1. Ugradar S, Bonelli L, Rootman D. Facial numbness in the ophthalmology clinic. A portentous sign. Eye (Lond). 2020 04;34(4):663–668. PubMed 31471563 ❐ PainSci Bibliography 52220 ❐

   This paper reports on fourteen people with facial numbness who sought care at an opthamology clinic (eye doctor). In all fourteen cases, facial numbness proved to be a symptom of serious illness, mostly skin cancers spreading along nerves, and some infections. Nine of these patients eventually died, and the remainder all had a rough ride: “significant morbidity.”

   Why did this study come from the world of eye medicine? Because some of the same things that cause eye trouble also cause facial numbness — and/or headaches and neck pain, which is why this might be of interest to some PainScience.com readers.

2. 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.
3. 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 Bibliography 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.

4. 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.

5. 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 Bibliography 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.”

6. 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 Bibliography 53624 ❐ “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.
7. 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].”
8. 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.
9. 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.
10. 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.
11. In the back, there are some noteworthy differences from side to side, but they are all visceral differences, and while problems with those structures may cause some back pain, it’s usually overshadowed by adominal pain. The neck has no such complexities. The neck is really and truly as symmetrical.
12. 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.

13. 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.
14. 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 a case you will already know that you have a big problem! The scan is just clarifying why. Maybe.
15. Lei S, Jiang F, Su W, et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection. EClinicalMedicine. 2020 2020/04/06. PainSci Bibliography 52605 ❐
16. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). Accessed 2020-04-06.
17. The symptoms of most infections are not directly caused by damage they do to our tissues, especially at first. We cannot feel cells being killed by a virus; what we actually do feel is our immune system’s reaction to the invasion. One purpose of that reaction is to force us to stay still — also known as rest — mostly by making movement feel incredibly difficult and unpleasant. This “sickness behaviour” is a generalized reaction to a wide variety of biological threats found in all animals (see subtle systemic inflammation).
18. NewYorker.com [Internet]. Cook G. The Nocebo Effect: How We Worry Ourselves Sick; 2015 May 13 [cited 15 May 13]. PainSci Bibliography 54175 ❐

    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.

19. 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!
20. 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 ❐