How do I treat a strained neck?

Treatment of Acute Neck Strain

For an acute strained neck, initiate treatment with NSAIDs (such as ibuprofen 400mg three times daily) combined with short-term muscle relaxants (cyclobenzaprine for 2-3 weeks maximum), along with early mobilization and physical therapy rather than prolonged rest. 1, 2, 3

Initial Pharmacologic Management

First-Line Medications

• NSAIDs are effective for acute neck pain and should be the primary analgesic choice 3
• Ibuprofen 400mg orally three times daily is an appropriate starting regimen 2, 4
• Muscle relaxants provide additional benefit when used as adjuncts to NSAIDs for acute painful musculoskeletal conditions 1, 3
• Cyclobenzaprine is FDA-approved specifically for relief of muscle spasm associated with acute, painful musculoskeletal conditions 1
• Limit muscle relaxant use to 2-3 weeks maximum, as adequate evidence for longer use is not available and acute muscle spasm is generally short-duration 1

Important Medication Considerations

• Monitor for GI side effects with NSAIDs, including ulceration and bleeding risk 2
• Avoid NSAIDs in patients with aspirin sensitivity, pre-existing asthma, or cardiovascular risk factors 2
• Be aware that ibuprofen can interfere with low-dose aspirin's antiplatelet effects if taken before aspirin 2
• Cyclobenzaprine is not effective for spasticity from neurologic conditions, only for acute musculoskeletal muscle spasm 1

Physical Modalities

Heat vs. Cold Therapy

• Either heat or cold packs provide similar mild pain relief when added to NSAID therapy 4
• Apply heating pad or cold pack for 30 minutes to the affected area 4
• Choice between heat and cold should be based on patient preference and availability, as efficacy is equivalent 4
• Most pain relief likely derives from the NSAID rather than the topical therapy 4

Physical Therapy and Exercise

• Exercise has the strongest evidence among complementary treatments for neck pain 3
• Early mobilization is preferred over prolonged rest 5
• Manual therapy and therapeutic exercise should be initiated early in the treatment course 5

Red Flags Requiring Further Evaluation

When to Suspect More Serious Pathology

• Elevated inflammatory markers (such as CRP) warrant MRI evaluation to rule out infection or inflammatory processes 6
• Recent history of swollen lymph nodes combined with pain on swallowing suggests possible inflammatory or infectious etiology 6
• Minimal response to appropriate NSAID therapy indicates potential for more serious underlying condition 6
• Neurologic symptoms including radicular pain, weakness, or paresthesias require advanced imaging 7

Cervical Strain vs. Concussion-Associated Cervical Injury

• When neck strain occurs with head trauma, assess for concurrent concussion 7
• Clinical signs warranting concern include: midline cervical spine tenderness, paraspinal muscle tenderness, weakness on myotome testing, limitation of cervical motion, and radicular symptoms in upper extremities 7
• Cervical strain and concussion share common injury mechanisms, making differentiation important for appropriate management 7

Treatment Duration and Follow-Up

• Most acute neck pain episodes resolve spontaneously with conservative treatment 3
• If symptoms persist beyond 2-3 weeks despite appropriate therapy, consider re-evaluation for alternative diagnoses 1, 3
• More than one-third of patients may have low-grade symptoms or recurrences beyond one year, with psychosocial factors being risk factors for persistence 3
• Genetics and psychosocial factors predict chronicity and should be addressed early 3

Common Pitfalls to Avoid

• Do not prescribe antibiotics routinely for neck pain unless clear signs of bacterial infection are present 7
• Avoid prolonged use of muscle relaxants beyond 2-3 weeks without reassessment 1
• Do not assume degenerative changes on imaging correlate with symptoms, as they are common in asymptomatic individuals 6
• Do not delay imaging when red flags are present, particularly elevated inflammatory markers or neurologic symptoms 6