Neck pain: causes, red flags and when to see a GP

The neck holds up the head and allows it to turn and tilt, using seven small vertebrae, discs, joints and many muscles, with nerves to the arms leaving between the bones. NICE CKS describes simple, or non-specific, neck pain as discomfort in the neck or shoulder girdle, with or without pain spreading to the arms, for which in most cases no specific cause is found. It is usually multifactorial: poor posture, neck strain, sport or occupation, anxiety and depression.

Symptoms vary with activity and over time. The NHS suggests that a locked neck on waking, a long day at a screen, or a minor strain explains most neck pain.

The table sets out the causes named in NHS and NICE sources and how they usually present.

The NHS neck pain page says to see a GP if pain or stiffness does not go away after a few weeks, painkillers have not worked, or you have other symptoms such as pins and needles or a cold arm. The NHS cervical spondylosis page is more specific. For an urgent GP appointment or 111: severe neck pain that starts suddenly or is getting worse quickly, heaviness or weakness in the arms or legs, and pins and needles in an arm as well as neck pain. For 999: new problems walking, loss of bladder or bowel control, sudden lack of coordination such as difficulty buttoning a shirt, a drooping face on one side, being unable to lift both arms and keep them there, and slurred or garbled speech.

After an injury, the NHS whiplash page says to ask for an urgent GP appointment or 111 if you have severe pain despite paracetamol or ibuprofen, tingling or pins and needles on one or both sides of the body, problems walking or sitting upright, a sudden electric shock feeling in the neck and back that may go into the arms and legs, or weak hands, arms or legs. It says not to do anything dangerous, such as driving or cycling, until you have spoken to a GP or 111.

Stiff neck with fever, severe headache, a rash that does not fade when pressed with a glass, dislike of bright lights or drowsiness is meningitis until proven otherwise, according to the NHS symptom list, and needs 999 or A&E. CKS adds fever, malaise, unexplained weight loss and unremitting pain affecting sleep as warning features.

• Sudden severe neck pain, or pain that is rapidly worsening.

• Weakness, heaviness or pins and needles in the arms or legs.

• New walking problems, clumsiness, or loss of bladder or bowel control.

• Facial droop, arm weakness or slurred speech.

• Fever, severe headache, dislike of light, drowsiness or a non-fading rash with a stiff neck.

• Neck pain after a significant accident, with tingling or an electric-shock sensation.

NICE CKS says assessment takes a detailed history and physical examination to tell neuropathic or other causes from mechanical neck pain, assesses for specific conditions such as whiplash, acute torticollis and cervical radiculopathy, and excludes red flags. The NHS says for cervical spondylosis that a health professional will examine the neck and shoulders, may test reflexes and watch you walk, and may arrange X-rays or scans depending on symptoms.

The questions cover onset and any injury, the pattern of pain, arm symptoms, headaches, work and posture, sleep, mood, cancer history and bone health.

Most people with typical neck pain need no tests. The NHS says X-rays or scans may be arranged depending on symptoms where cervical spondylosis or nerve problems are suspected. CKS says that when red-flag features are present, referral or admission is arranged depending on the severity of the findings.

CKS says people with chronic neck pain, lasting more than 12 weeks and not responding to primary-care measures, should be considered for referral to a pain clinic.

The NHS suggests paracetamol or ibuprofen, or ibuprofen gel on the neck, a low firm pillow, heat or cold packs and neck flexibility exercises. For packs it gives two examples: frozen peas wrapped in a tea towel for 5 minutes, 3 times a day, or a hot water bottle wrapped in a tea towel for 20 minutes, 2 to 3 times a day. It says not to wear a collar and not to do anything dangerous, such as driving or cycling, if you cannot move your neck.

To prevent recurrence the NHS advises that when sleeping your head is at the same height as the rest of your body, a firm mattress, sitting upright with shoulders back, not keeping the neck in the same position for long, not sleeping on your front and not twisting the neck in bed. CKS adds reassurance, staying active and sleeping with a single firm pillow.

A GP can assess neck pain that persists beyond a few weeks. In many areas people can refer themselves to NHS community musculoskeletal services for physiotherapy without a GP referral. CKS lists physiotherapy with stretching, strengthening and manual therapy, psychological support where appropriate, and occupational health for work-related neck pain.

Emergency services are for the red-flag combinations above.