The Complete Guide to Neck Pain & Cricks

Chronic neck pain matters. The seriousness of chronic pain is often expressed in terms of the hair-raising economic costs of work absenteeism, but it may be much worse than that — a recent Swedish study shows that it probably even shortens lives.4 The stakes are high. The quality of a life can be ruined, at least. And yet there is an enormous amount of misinformation about neck pain.5 Only low back pain rivals neck trouble for the sheer tonnage of half-baked theories, even from doctors. Most GPs are not really competent to treat neck pain, or any other difficult musculoskeletal problem.6

For instance, there is a common idea out there that neck pain is related to abnormal cervical spine curvature, perhaps from poor posture. So many professionals believe this over-rated idea that you could probably get a hundred second opinions in a row without hearing differently. And yet research has virtually proved that the neck posture hypothesis is either dead wrong or at least an underwhelming non-problem. For instance, we know that “text neck” is not actually a thing, despite much fear-mongering to the contrary: regularly staring down at a phone has no clear connection to any kind of neck trouble.7

Abnormal vertebrae? Who cares …

Research has shown that abnormal curvature of the cervical spine is not closely associated with neck pain.

But the reassuring news hasn’t gotten out, and the bogeyman of abnormal neck shape continues to be the basis of lots of expensive manual therapy that doesn’t work particularly well.8 Such ideas can be amazingly persistent. Neck pain myths are as stubborn as neck pain itself. I am sure that in ten years there will still be many professionals fixated on neck posture.

This tutorial carefully debunks many other misconceptions about neck pain — myths about subluxation and the spine being “out,” myths about muscle strain and muscle spasm, myths about arthritis and herniated discs and nerve pinches, and more — and it does it with great care to refer to and explain recent scientific research.9 I have no tidy, too-good-to-be-true theory of neck pain to replace any of these ideas with, but there are certainly lots of miscellaneous recommendations.

Who exactly is this tutorial for?

Head pain, face pain, and neck pain are huge topics: this tutorial focuses on cricks and chronic unexplained neck pain and closely related symptoms in the upper back and shoulders (upper backs get “cricks” too).

It is not about face and jaw pain; neck pain with prominent nerve symptoms (tingling, numbness, zapping pain) in the arm; headaches10; and fresh whiplash, or other acute neck trauma.11 Some safety information is provided below for the rare cases of neck pain that may be caused by systemic and/or serious disease, but otherwise this page is not about neck pain with a pathological origin.

What about injury?

Car accidents are at least twice as likely to be part of a chronic neck pain story than a fight with back pain.12 And people who have an accident when they are already stressed and suffering from other kinds of pain are up to five times more likely to develop chronic neck pain13 — in fact, those risk factors are far more important than the particulars of the accident! This is one of the strange truths of neck pain.

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Neck cricks and neck pain often go together, affecting about 50% of adults per year,15 ranging in severity from trivial to crippling.

“Crick” is an informal term, but perhaps it shouldn't be, because it’s a major sub-type of neck pain. It feels like something in a joint is catching or sticking or locking when you try to move, a seemingly mechanical failure. Many neck crick sufferers insist that the problem is not exactly painful, but still extremely unpleasant — a sensation of stuckness that is “irritating” or “uncomfortable” or “stuck” or more like an “itch” or perhaps a “deep itch” than an actual pain.

Because a crick often does not hurt, per se, it is often underestimated and neglected, even by the patient. The use of that word “crick” can trivialize the problem. When it exceeds a certain degree of badness, no one calls it a “crick” anymore — the word feels too lightweight.

Never underestimate the power of a neck crick to make a person perfectly miserable. Not all pain is painful. It is possible to suffer deeply without hurting. A feeling of stuckness can be every bit as bad as severe pain. Cricks will nag and irritate to the point of nearly driving people out of their minds — a serious mental health hazard, no exaggeration. I have seen people showing every sign of severe chronic psychological distress, unable to function well mentally because their neck will not stop harassing them.

I’ve also experienced that state personally, once.

Although it’s like comparing apples to orange cars, I have often had the impression that irritating cases are more tragic than painful cases, causing more emotional distress — suffering — and mental preoccupation than pure pain. There is something profoundly unsettling about this kind of discomfort. I get email from readers around the world who recognize their predicament in these words, and want to reach out just to say, “Yeah, that’s me!”

So cricks make neck pain particularly “interesting,” in the sense of the Chinese curse.16 They are a simple sensation that no one can really explain. Not every case of neck pain includes a crick, but the terrible neck injuries and pain problems of today often become the persistent cricks of tomorrow. Pain and nagging stuckness are generally interwoven and the lines between them thoroughly blurred. So this tutorial is about both, but with a strong emphasis on the exasperating phenomenon of a crick.

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Maybe you have a pinched nerve … and maybe you don’t. As with whiplash, this tutorial is useful to many people who have a troubled nerve root (radiculopathy). Even when such pain exists — less than people assume — it may prove to be a surprisingly minor problem that goes away on its own, or when other neck issues are addressed. Severe cases of nerve pain are not addressed directly in this book, but I do put the topic in some perspective — and that can be helpful to many patients, particularly those who aren’t too sure about their diagnosis.

Reading on is a great way to settle this unsettling issue in your mind once and for all. There is a section devoted to the many common misconceptions about nerve pain; another section to help you identify nerve pain (or the lack of it); and a third section about safety issues related to massaging around nerves in the neck.

If you have significant or persistent tingling and numbness in the arms and hands, then the tutorial may be interesting and useful to you, but it will not focus on the options for your problem. Surgery is a more realistic option for patients in this category, but — not being a surgeon — I do not discuss surgery much. The value of this tutorial to such patients is that you might discover a way to avoid surgery.

The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis).

Teaching people about pain — why do we keep beating around the bush?, by Lorimer Moseley, 2–3

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“How do you know I’m not seriously hurt?”

“Could it be cancer? A tumor?”

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 three 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! 😉

In all other cases, you can safely read this tutorial first.

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.

• 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.23
• Any severe headache that comes on very suddenly is colourfully called a “thunderclap headache”! There are many causes and most are harmless, but they should always be investigated.24
• Severe, novel pain (throbbing or constrictive) may be caused by an artery tear252627 with a high risk of a stroke. Pain is the only symptom of some tears! Most but not all cases28 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.29 Any hint of other symptoms?30 Go to the ER.
• There are many possible symptoms of spinal cord trouble in the neck,31 with or without neck pain, mostly affecting the limbs in vague ways that can have other causes, but especially poor coordination, weakness, and shooting pains (including “sciatica” in the legs32). Bizarrely, cord compression may even cause fibromyalgia.33 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.” )
• 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.34
• 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.

For more detail and ideas, see When to Worry About Neck Pain … and when not to!

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

Infamously, meningitis causes severe neck pain and stiffness. That is not specifically a prominent feature of COVID-19 so far, or of any other systemic infection. Infections always lower our pain thresholds, and so 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,35 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 occurs in 8–14% of cases.3637).

So, 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.

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“Sensitization” is the tendency of the nervous system to get into a rut and start over-reacting to stimuli, an alarm system getting set off too easily.38 This is a well-described property of pain,39 the crown jewel of modern pain science,40 and evidence that either there is no God or only a cruel one. As a general rule, the longer any kind of pain lasts, the more likely sensitization is to become a factor, and even to take over and become the main problem. So it’s an important factor to understand.

Sensitization can complicate any chronic pain problem, and as my career lengthens I find myself writing about it more and more: all painful roads seem to lead to this topic. There is great variety in acute pain, but chronic pain is often defined by sensitization, regardless of how it all started.

And yet pain can also begin with sensitization, too. Certain kinds of pain — especially neck pain, back pain, and abdominal pain — can be the tip of a sensitization iceberg. And that’s why I’ve chosen to introduce this idea in the context of prognosis and “worst-case scenarios” — because sometimes neck pain is just the beginning of something more sinister. There’s a risk of scaring you here, so let’s keep a level head and remember that the vast majority of neck pain goes away and is not the tip of an evil iceberg … and there’s still plenty of hope even when it is.

But I’m not going to sugarcoat it: this is something you need to be aware of.

The gender connection

Interestingly, women suffer from neck pain much more than men do. (There’s got to be a joke at the expense of husbands here somewhere.) According to Côté et al., women are 60% more likely than men to develop neck pain, and 20% more likely to develop chronic neck pain.

And, suspiciously, women also suffer from higher rates of other kinds of chronic pain. For instance, they get diagnosed with fibromyalgia much more often than men. Fibromyalgia is a diagnostic label for unexplained chronic widespread pain and fatigue (among other things), which seems to involve a lot of sensitization. It often begins with stubborn regional pain in guess what regions? The neck and shoulders, the low back, the abdomen. Many fibromyalgia patients start their journey to hell with recurrent episodes of pain in these areas, and then eventually the pain spreads and other classic fibromyalgia symptoms start to appear.41

Why women? No one knows. (But I do have a pet theory about this, which I’ll relegate to a footnote because it’s too speculative to clutter the main text with.42)

Which came first, the neck pain chicken or the sensitization egg?

How do we know that neck pain can be the beginning of sensitization? Could the neck pain just be ordinary neck pain at first, and then sensitization sets in over time as a complication … and then spreads, like an infection? Yes, it’s possible. But most people who end up with sensitization can recall subtle, early symptoms of sensitization dating all the way back to the beginning of their troubles. Neck pain was the main problem and other clues were overlooked or filed under “odd,” too vague and minor to interpret.

But surely sometimes the chicken does come first! In this other worst-case scenario, sensitization didn’t start it, but it is the main reason that your neck keeps hurting — even if it never progresses to causing widespread symptoms. Probably most chronic pain gets complicated by sensitization eventually, if not all of it, and some chronic cases are chronic not because there’s still something wrong with your neck tissues after all these years, but simply because your brain has set up a permanent ban on full neck movement (and pain is the main way the brain does that). This is why every chronic pain patient needs to know about sensitization.

To sum up, central sensitization is involved in two kinds of worst-case scenarios for neck pain:

1. Neck pain may simply be the first, worst symptom of sensitization (along with, perhaps, back and/or abdominal pain).
2. Neck pain may become chronic due to sensitization that develops as a reaction to some original problem, a permanent case of “false alarm” that stays confined to the neck.

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Nasty Case #1: The one about the guy who had suffered for 35 years and couldn’t stop wrenching his neck around

This was by far the worst case I encountered in my decade as a massage therapist: a middle-aged man who had suffered ever since a serious motorcycle accident in his youth. The overall intensity of pain had been routinely debilitating, but was always greatly exacerbated by a maddening sensation of stuckness just under his skull — a whopper of a classic crick, an itch he had been trying to scratch for three and a half decades by squirming and “wrenching” (his word) violently from side to side.

This wrenching behaviour was so severe and so habitual that it was a major feature of his identity, like a tic — and when he stopped doing it, friends and family were amazed.

His story is not only a good example of a worst-case scenario, but it’s also instructive about the nature of neck cricks. It’s hard to imagine a crick more mechanical than his, and indeed he had received hundreds of temporarily helpful chiropractic treatments over the years. “Usually it would be ‘out’ again within minutes or hours,” he explained to me. That’s the notorious “parking lot effect”: you get relief, but so briefly that you’re already back in trouble again by the time you get out to the parking lot…

Testimonials on health care websites reek of quackery, so publishing them has always made me a bit queasy. But my testimonials are mostly about the quality of the information I’m selling, and I hope that makes all the difference. So here are some highlights from the kind words I’ve received over the years … plus some of the common criticisms I receive, at the end. These are all genuine testimonials, mostly received by email. In many cases I withold or change names and identifying details.

Thank you for such helpful, intelligent information on neck issues. I am so thankful that I read your information and no more. You answered every lingering question and are persuasive in counselling calm and patience.

Virginia Avila, Retired Teacher & Attorney

Your book is so comprehensive and outlines a lot of what I have also found, with more explanation and scientific backing, and then expands upon it. I purchased it this afternoon and have read it almost cover to cover all afternoon and evening!

Tanvir England

I never had severe neck pain except for the occasional bad day, but it was stubborn. I’ve never really had any relief from it ever, always a low grade ache. Every therapist I ever saw told me it was posture, and every doctor said it was arthritis (even though it started in my 20s). Your tutorial clearly explains several other possibilities, and it’s mostly under control now just from a little bit of self-treatment of my muscles once every week or two. It’s not “cured,” but it’s about a hundred times less irritating than it was. Thank you!

Laurie Pappas, Denver, unusually busy home-maker, mother of seven

After thirty-five years with severe constant neck pain, I am 80% better, and I feel like I can actually enjoy the rest of my days. Paul Ingraham helped me understand that the problem with my neck wasn’t ‘structural.’ Even though it felt like something was ‘out,’ that’s not really what was happening. I’d seen every kind of therapist you can imagine, and no one ever explained it so clearly. I had my doubts at first, but the results of applying his ideas have been nothing short of miraculous. I used to wrench my neck all day long, always twisting and turning trying to get away from that damn crick! And now? People who don’t even know me that well are saying to me, ‘Hey, Elliott... you’re not twisting your neck around the way you used to!’ If you’ve got a stiff neck, I can’t recommend Paul Ingraham’s perspective on it strongly enough.

Trevor Elliott, real estate speculator

After Googling ‘neck knot’ I read an article on some ask-the-clinician site which was pretty useless, and then tried yours. It was exactly the information I was looking for! Your article affirmed some of my own theories and enlightened me with more detailed information. You’re a thorough and organized writer.

Cheryl Sosebee, artist

One more noteworthy endorsement, with regards to this whole website and all of my books, submitted by a London physician specializing in chronic pain, medical education, and patient-advocacy (that’s a link to his excellent blog):

I’m writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

What about criticism and complaints?

Oh, I get those too! I do not host public comments on PainScience.com for many reasons, but emailed constructive criticism, factual corrections, requests, and suggestions are all very welcome. I have made many important changes to this tutorial inspired directly by critical, informed reader feedback.

But you can’t make everyone happy! Some people demand their money back (and get it). I have about a 1% refund rate (far better than average in retail/e-commerce). The complaints of my most dissatisfied customers have strong themes:

• Too negative in general. Some people just can’t stomach all the debunking. Such customers often think that I dismiss “everything” … which I disagree with.
• Too negative specifically. Some are offended by my criticisms of a treatment option that they personally use and like. Or sell!
• Too advanced. Although I work hard to “dumb” the material down, quite a few people still just find it too dense and dorky.
• Too simple. Some people think they already know everything about the topic. Maybe they do, and maybe they don’t. I always wish I could give these readers a pop quiz. 😉 In my experience, all truly knowledegable people get that way by embracing every new persective and source of information.

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Thanks to every reader, client, and book customer for your curiosity, your faith, and your feedback and suggestions, and your stories most of all — without you, all of this would be impossible and pointless.

Writers go on and on about how grateful they are for the support they had while writing one measly book, but this website is actually a much bigger project than a book. PainScience.com was originally created in my so-called “spare time” with a lot of assistance from family and friends (see the origin story). Thanks to my wife for countless indulgences large and small; to my parents for (possibly blind) faith in me, and much copyediting; and to friends and technical mentors Mike, Dirk, Aaron, and Erin for endless useful chats, repeatedly saving my ass, plus actually building many of the nifty features of this website.

Special thanks to some professionals and experts who have been particularly inspiring and/or directly supportive: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Mark Crislip, Scott Gavura, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Lars Avemarie, PT, Dr. Brian James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, James Fell, Dr. Ravensara Travillian, Dr. Neil O’Connell, Dr. Tony Ingram, Dr. Jim Eubanks, Kira Stoops, Dr. Bronnie Thompson, Dr. James Coyne, Alex Hutchinson, Dr. David Colquhoun, Bas Asselbergs … and almost certainly a dozen more I am embarrassed to have neglected.

I work “alone,” but not really, thanks to all these people.

I have some relationship with everyone named above, but there are also many experts who have influenced me that I am not privileged to know personally. Some of the most notable are: Drs. Lorimer Moseley, David Butler, Gordon Waddell, Robert Sapolsky, Brad Schoenfeld, Edzard Ernst, Jan Dommerholt, Simon Singh, Ben Goldacre, Atul Gawande, and Nikolai Boguduk.

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• Unexplained episodes of nausea and vomiting, combined with neck pain? See 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.
• Massage Therapy for Tension Headaches — Perfect Spot No. 1, in the suboccipital muscles of the neck, under the back of the skull.
• 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
• Massage Therapy for Bruxism, Jaw Clenching, and TMJ Syndrome — Perfect Spot No. 7, the masseter muscle of the jaw
• The Complete Guide to Chronic Tension Headaches — A detailed, science-based tour of stubborn headache diagnosis and treatment, for both patients and professionals
• The Complete Guide to Low Back Pain — An extremely detailed guide to the myths, controversies, and treatment options for low back pain
• The Trouble with Chairs — The science of being sedentary and how much it does (or doesn’t) affect your health and back pain
• The Complete Guide to Trigger Points & Myofascial Pain — An extremely detailed guide to the unfinished science of muscle pain, with reviews of every theory and treatment option
• The Not-So-Humble Healer — Cocky theories about the cause of pain are waaaay too common in massage, chiropractic, and physical therapy
• Singing, Breathing, and Scalenes — Connections between singing, breathing, neck pain, and a strange group of muscles
• The Respiration Connection — How dysfunctional breathing might be a root cause of a variety of common upper body pain problems and injuries

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The first version of this document was created in 2002. It was upgraded and expanded several times before I started keeping track of updates and put it up for sale in September of 2007. It was revised and expanded to book-length in the summer 2009, and continues to be updated as new scientific information becomes available, and in response to reader requests and suggestions.

Regular updates are a key feature of PainScience.com tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 142 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

Apr 25, 2025 — Major science update: After years of underwhelming and mixed evidence, a new 2025 review has concluded that spinal injections and nerve ablations are collectively very unimpressive … and the doctors have responded with demands for retraction of the evidence. It’s not a good look. [Updated section: Kill it with fire! Treatment by nerve destruction.]

February — New chapter: A significant new overview of medical testing for specific causes of back pain, one of those “basic” topics that was missing from the original, quirkier version of the book for too many years. This is a good step towards rounding it out and making it a more complete guide to the topic for a wider range of readers. [Updated section: Medical tests for specific causes: an introduction to doctorly diagnosis.]

February — New chapter: Major new chapter, adding much more detail (2800 words!) about the art and science of diagnosing specific causes of neck pain with a physical examination. [Updated section: Diagnose, schmiagnose! Physical exam accuracy is poor.]

2023 — Revised: After several years without much attention, this chapter has finally gotten a variety of improvements. [Updated section: Diagnose, schmiagnose! Physical exam accuracy is poor.]

2022 — Added footnote: Explained and justifed my opinion that morning onset cricks may often be related to the combination of chilling neck skin at night. [Updated section: A classic diagnostic sign: “I woke up with it”.]

2021 — Science update: Almost an echo of last year’s science update on this topic: a second study of needling for neck pain, also quite good, and also quite negative. [Updated section: “Acupuncture”: Dry needling for trigger points (acupuncture’s weird cousin).]

2021 — New red flag: Added “facial numbness,” based on Ugradar et al. [Updated section: “What if there’s something really wrong with my neck?” Safety information!]

2021 — New silly treatment: Added frenuloplasty to the hall of treatment shame. [Updated section: Hall of Treatment Shame: some popular treatments that are particularly silly.]

2021 — Improvements: More detail and polish. [Updated section: Strain-counterstrain (AKA positional release): find a neutral, comfy position and rest there.]

2021 — Upgrades: More and better information, mostly achieved in this case by consolidating information from other books in the PainSci library. [Updated section: Is it a pinched nerve? Rarely! The nerve pinch myth.]

2020 — New section: Adapted and expanded from an old chapter in my muscle pain book, with more detail and a neck pain example. [Updated section: Strain-counterstrain (AKA positional release): find a neutral, comfy position and rest there.]

2020 — Science update: No obvious changes, but I carefully reviewed and upgraded and fine-tuned some of the referencing in this section. I also added a bit about the history of prejudice against whiplash patients. [Updated section: Neck pain myths busted here!]

2020 — New chapter: No notes. Just a new chapter. [Updated section: Hung on a coat hanger: coat hanger pain and dysautonomia.]

2020 — Improved: A thorough editing and cleanup, with some information added, most notably the most positive science on the topic. [Updated section: “Acupuncture”: Dry needling for trigger points (acupuncture’s weird cousin).]

2020 — Science update: A nail-in-coffin study of needling for neck pain has been published. I may never have to update this chapter ever again. (Ha, fat chance!) [Updated section: “Acupuncture”: Dry needling for trigger points (acupuncture’s weird cousin).]

2020 — Added case study: An interesting and credible case study about a clear case of spinal degeneration with counter-intuitive consequences. [Updated section: Could it be arthritis? Is your spine degenerating? Probably not, no.]

2020 — COVID-19 update: Added information about headaches as a symptom of COVID-19. [Updated section: “What if there’s something really wrong with my neck?” Safety information!]

2019 — Science update: Added several interesting details about nerve root compression symptom pattern variability, with references. [Updated section: How can I tell if there’s a pinched nerve?]

2019 — New section: Previously coverage of muscle relaxants was limited to a small section of the medications chapter. This new chapter provides about 10x more information. [Updated section: Muscle relaxants (Robaxin, Robaxacet, etc), psychoactives, and sedatives.]

2019 — New section: No notes. Just a new chapter. [Updated section: The cannabinoids: marijuana and hemp, THC and CBD — “it’s complicated!”.]

Archived updates — All updates, including 122 older updates, are listed on another page. ❐

2006 — Publication.

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1. Dear BF, Gandy M, Karin E, et al. The Pain Course: A Randomised Controlled Trial Examining an Internet-Delivered Pain Management Program when Provided with Different Levels of Clinician Support. Pain. 2015 May. PubMed 26039902 ❐

   Chronic pain may be treatable with tutorials like this one. Researchers tested a series of web-based pain management tutorials on people who had been suffering for more than six months. No matter how much (or little) help they had from doctors and therapists, they all experienced significant reductions in disability, anxiety, and average pain levels, for at least three months.

   (See more detailed commentary on this paper.)

   See a more rigorous analysis of the study.
2. Brison RJ, Hartling L, Dostaler S. A randomized controlled trial of an educational intervention to prevent the chronic pain of whiplash associated disorders following rear-end motor vehicle collisions. Spine. 2005 Aug 15;30(16):1799–807. PubMed 16103847 ❐

   This is one of a few studies showing a benefit to education for neck pain specifically. Researchers showed a reassuring educational video to more than 200 patients with “whiplash associated disorders” (i.e. whiplash injuries that become chronic neck cricks), and found that they had less severe symptoms than patients who received no educational intervention. The effectiveness of education probably depends a lot on the type of neck pain and the type of education, making it very hard to study. A recent review of the scientific literature found that most such studies are negative (see Haines or Ainpradub), but I believe that there are still reasons to be optimistic about education for pain problems. Above all, it depends on the type and quality of the education! The right education may be effective, and the wrong could even be harmful. The fact that some education has been shown to be beneficial is promising.

3. The best recent evidence of this is a 2008 study in Journal of the American Medical Association that showed that “spine-related expenditures increased substantially from 1997 to 2005, without evidence of corresponding improvement in self-assessed health status” (see Martin). In other words, a lot of expensive medical care is not helping. This interesting paper was summarized well by Parker-Pope in the New York Times.
4. Jansson C, Mittendorfer-Rutz E, Alexanderson K. Sickness absence because of musculoskeletal diagnoses and risk of all-cause and cause-specific mortality: A nationwide Swedish cohort study. Pain. 2012 May;153(5):998–1005. PubMed 22421427 ❐

   Can pain shorten your life? A large study of four million Swedes looked for a correlation between increased mortality and work absenteeism due to painful musculoskeletal conditions. They found the first ever evidence that people who have musculoskeletal pain may have “an increased risk of premature death.” The researchers adjusted their data for “several potential confounders.” It’s a plausible and disturbing conclusion. The costs of pain are often expressed in terms of hair-raising stats on the economics of work absenteeism — but they may be much greater still.

5. In 2012, the The Journal of Foot & Ankle Surgery ranked 136 websites about common foot and ankle diagnoses. Expert reviewers gave each a quality score on a scale of 100. The average score? Just below fifty. Fifty! See Smith et al.

   Or see Starman et al. for a review of other kinds of health care information (with nearly identical grades).

   P.S. These references are aging now… but nothing’s really changed!

6. Most doctors lack the skills and knowledge needed to care for common aches, pains, and injury problems, especially the chronic cases, which they tend to underestimate the complexity of. This has been shown by many studies, like Stockard et al., who found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.” It’s just not their thing, and people with puzzling or stubborn pain should take their family doctor’s advice with a large grain of salt, and even lower their expectations of specialists (who tend to be too specialized). See The Medical Blind Spot for Aches, Pains & Injuries: Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones.

   Comic by Loren Fishman, HumoresqueCartoons.com

7. Damasceno GM, Ferreira AS, Nogueira LAC, et al. Text neck and neck pain in 18-21-year-old young adults. Eur Spine J. 2018 Jan. PubMed 29306972 ❐

   This study of 150 young adults found no link between neck pain and poor posture while texting, so-called “text neck.” The possibility of a link emerging over many years of text-neck posture has yet to be investigated, but this suggests that any long term link is probably minor, or there would be at least some detectable short-term link.

   (See more detailed commentary on this paper.)

8. The standard techniques of physiotherapists, massage therapists, and chiropractors all produce generally poor results with neck pain: they work a little bit, sometimes, with some people, temporarily. Truly good success stories are rare. This lacklustre performance was confirmed in 2010 by a new study of studies (a meta-analysis) in Manual Therapy (see D’Sylva). Although the science is complex and limited and about 75% of studies had to be eliminated from consideration due to likely bias, one thing was clear: manual therapy isn’t exactly curing a lot of neck pain. It has “low to moderate quality evidence” that it’s helpful, compared to advice and exercise alone.
9. We have recently emerged from something of a dark period in the scientific study of neck pain. Always something of a poor cousin to low back pain research, there was a surprising lack of analysis of neck pain research available — perhaps because of a lack of research to analyze. According to the journal Spine in early 1998, “No comprehensive systematic literature reviews have been published on interventions for neck pain and its associated disorders in the past decade” (see Hurwitz). However, since then there have been many important new studies, and much more analysis. Although this tutorial is many years old, it was significantly renovated throughout 2009 to include this new science, and will continue to be updated indefinitely.
10. Many headaches are probably caused by neck issues: “cervicogenic” headaches are “from the neck,” a whole class of headaches (and somewhat controversial actually, and therefore interesting). A future edition of the tutorial will probably cover them, but for now it’s big enough. If headache is your main problem, and it seems to be related to neck pain, the tutorial is worthwhile. For patients who are experiencing headaches and migraine without clear neck pain, I recommend other resources, such as Jim Cottrill’s excellent migraine blog. And see also my own tension headache tutorial.
11. While face and jaw pain often do occur with neck pain, and there is probably a relationship between them, they involve many special issues. This tutorial does not address them in any detail.
12. Freeman MD, Croft AC, Rossignol AM, Centeno CJ, Elkins WL. Chronic neck pain and whiplash: A case-control study of the relationship between acute whiplash injuries and chronic neck pain. Pain Res Manag. 2006;11(2):79–83. PubMed 16770448 ❐ PainSci Bibliography 57032 ❐ The histories of a few hundred adults with neck or back pain were compared, and motor vehicle accidents were a whopping 2-4 times as common in folks with neck pain. The authors concluded: “ … it is reasonable to infer that a significant proportion of individuals with chronic neck pain in the general population were originally injured in a motor vehicle accident.” Indeed.
13. Atherton K, Wiles NJ, Lecky FE, et al. Predictors of persistent neck pain after whiplash injury. Emerg Med J. 2006 Mar;23(3):195–201. PubMed 16498156 ❐ PainSci Bibliography 56091 ❐

    In this study of 480 people with neck pain after car accidents, 27% were still suffering twelve years later. Those chronic cases were also the injuries that were the worst to begin with, of course, they also reported dramatically more pre-accident vulnerability, like psychological stress and other kinds of pain. In fact, people who went into the accident in poor shape were five times more likely to have chronic pain. “The greatest predictors of persistent neck pain … relate to psychological distress and aspects of pre-collision health rather than to various attributes of the collision itself.”

    This phenomenon has also been confirmed by other research (see Carstensen).

    (See more detailed commentary on this paper.)

14. Crowe HE. The meeting of the Western Orthopedic Association. San Francisco: 1928. Injuries to the cervical spine.
15. Bahr R, Mæhlum S. Clinical guide to sports injuries. Human Kinetics; 2004. p106.
16. Interestingly, the “interesting” curse is probably not Chinese, but English or American. According to Wikipedia, “The Chinese language origin of the phrase, if it exists, has not been found, making its authenticity doubtful.” Also interesting, regardless of its provenance, is that it is the first of three curses, the other two being: (1) may you come to the attention of those in authority, and (2) may you find what you are looking for.
17. Neck pain that escalates steadily to crippling levels over weeks or months is more likely to be caused by disease. If this is your problem, please review the safety section! Also, although the worst cases of neck pain can certainly cause “severe” pain, I only mean severe for neck pain and not “off the scale” pain that blots out the sun and makes it impossible to function or work. The worst non-ominous neck pain is roughly the intensity of the worst tension headaches … but definitely not like a full-blown migraine, child birth, or rheumatoid arthritis.
18. Leaver AM, Maher CG, McAuley JH, et al. People seeking treatment for a new episode of neck pain typically have rapid improvement in symptoms: an observational study. J Physiother. 2013 Mar;59(1):31–7. PubMed 23419913 ❐ This study of 180 patients who sought treatment for a new case of neck pain found that more than half “recovered completely within three months,” and most of the rest did fairly well. The authors believe that “physiotherapists should reassure people with a new episode of neck pain that rapid improvement in symptoms is common.”

19. It’s hard to be sure, of course, because there are so many ways of measuring. The most optimistic estimates for back pain I’ve seen, from a 1994 paper (Coste et al.), reported 90% recovered within two weeks — definitely better than most of the neck pain data. Another rather hopeful example is Costa et al., which showed that Chronic Low Back Pain Is Not So Chronic. At the other end of the scale, the least promising recovery data about back pain is about the same as what Côté et al. found for neck pain.

    Yes, I just cited Coste, Costa, and Côté — completely coincidental. 😃

20. Kjellman G, Oberg B, Hensing G, Alexanderson K. A 12-year follow-up of subjects initially sicklisted with neck/shoulder or low back diagnoses. Physiotherapy Research International. 2001;6(1):52–63. PubMed 11379256 ❐

    This study was based on a survey of 155 Swedish patients who had suffered an episode of neck or back pain 12 years prior, severe enough that they missed at least a month of work. They all answered a questionnaire about their current status, revealing a striking pattern: 96% of those who’d had neck and shoulder pain were still suffering to some degree, compared to just 75% of those who’d had back pain.

    Based on this data, having a nasty episode of neck and back pain is a strong risk factor for developing extremely persistent symptoms, but “significantly more so for those initially having neck/shoulder diagnoses.”

21. I cited Leaver above as good news, because half of patients with new cases recover within three months. But it’s obviously good-and-bad-news science, because of the other half: “almost half of those who seek treatment do not recover completely within three months.” Which is actually quite a high number.
22. Côté P, Cassidy JD, Carroll LJ, Kristman V. The annual incidence and course of neck pain in the general population: a population-based cohort study. Pain. 2004 Dec;112(3):267–73. PubMed 15561381 ❐
23. 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.

24. 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.
25. 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.

26. 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.

27. 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.”

28. 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.
29. 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].”
30. 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.
31. 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. Some of the most common symptoms are poor hand coordination; weakness, “heavy” feelings, and atrophy; diffuse numbness; shooting pains in the limbs (especially when bending the head forward); an awkward gait.
32. Chan CK, Lee HY, Choi WC, Cho JY, Lee SH. Cervical cord compression presenting with sciatica-like leg pain. Eur Spine J. 2011 Jul;20 Suppl 2:S217–21. PubMed 20938789 ❐ PainSci Bibliography 53701 ❐

    A report on two cases of cervical spinal cord impingement causing leg pain — both examples of pain at a location unusually remote from a subtle lesion (referred pain) — both successfully treated surgically. Notably, both cases involved previous lumbar spine problems.

    Interestingly, such distant referred pain is tangentially relevant to the hypothetical phenomenon of cervical spinal cord irritation causing fibromyalgia (see Using Dynamic MRI to Diagnose Neck Pain).

33. PracticalPainManagement.com [Internet]. Holman A. Using Dynamic MRI to Diagnose Neck Pain: The Importance of Positional Cervical Cord Compression (PC3); 2017 January 12 [cited 17 Sep 1]. PainSci Bibliography 53754 ❐

    A remarkable article for a medical audience, technical and scholarly but cogent, exploring fascinating potential connections between PC3 and/or Chiari malformation and fibromyalgia and chronic widespread pain.

34. 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.

35. All systemic infections can cause body aches, fatigue, and fever, because these symptoms are functions of the immune system, not the disease — but some diseases, like COVID-19, provoke it more than others.

    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).

36. 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 ❐
37. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). Accessed 2020-04-06.
38. A more detailed definition: Pain itself often modifies the way the nervous system works, so that a patient actually becomes more sensitive and gets more pain with less provocation. This is often called “central” sensitization because it’s driven by the central nervous system, by changes in the spinal cord and brain (although there’s also peripheral sensitization). Sensitized patients are not only more sensitive to things that should hurt, but sometimes also to ordinary touch and pressure as well (allodynia). Their pain also often “echoes,” fading more slowly than in other people. Sensitization is closely associated with all the more serious chronic pain conditions.
39. Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2010 Oct;152(2 Suppl):S2–15. PubMed 20961685 ❐ PainSci Bibliography 54851 ❐
40. “Modern pain science” refers to the abandoment of the idea that pain is a relatively simple response to tissue damage. Instead, it’s an unpredictable top-down alarm system that responds to tissue conditions and many other variables, and has as much power to “mute” pain as it does to produce it. See Pain is Weird.
41. Debilitating fatigue, fragmented and shallow sleep, mental fog, depression, difficulty recovering from exercise. The quality of the pain may change from more ordinary “aches and pains” to more exotic and varied, more disconnected from reality, pain that just make no sense.

42. Here’s my chain of reasoning:

    1. One of the fascinating possible causes of fibromyalgia symptoms is intermittent spinal cord pinching (positional cervical cord compression, or “PC3,” a form of myelopathy, which is described in detail in the fibromyalgia article).
    2. It’s plausible PC3 is also associated with a certain amount of stubborn neck pain (which is indeed one of the most common troublesome areas in fibromyalgia patients).
    3. Finally, perhaps this scenario is more common in women for some reason, such as anatomical differences in the spine. A major 2016 study contradicts this point — women appear to have “milder evidence of degenerative cervical myelopathy” than men — but there are so many complex variables here that the hypothesis doesn’t need to be thrown out. And there are other reasons why women might be more vulnerable to positional cervical cord compression.

There are 399 more footnotes in the full version of the book. I really like footnotes, and I try to have fun with them.

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