What is the best approach to treat cervical strain due to trauma with mild pain and neck stiffness?

Treatment of Cervical Strain Following Trauma

For this patient with post-traumatic cervical strain presenting with delayed-onset headache, mild pain (3/10), and neck stiffness without neurological deficits, treat with ibuprofen 400-800 mg three times daily as needed, combined with early mobilization and avoidance of cervical collars. 1, 2

Initial Assessment and Red Flag Screening

Before initiating treatment, confirm the absence of serious pathology requiring urgent intervention:

• No "red flags" are present in this case: no constitutional symptoms (fever, weight loss), no neurological deficits, no severe intractable pain, and no risk factors for infection or malignancy 3, 4
• Delayed headache onset (3 days post-trauma) is consistent with whiplash-associated disorder (WAD) rather than serious intracranial pathology, particularly given the absence of loss of consciousness, photophobia, or nausea/vomiting 3
• Imaging is not indicated for this presentation, as the American College of Radiology guidelines state that imaging has limited value in WAD when clinical factors suggest mechanical injury without red flags 3

Pharmacologic Management

First-line treatment is NSAIDs alone:

• Ibuprofen 400 mg every 4-6 hours as needed is the appropriate starting dose for mild to moderate pain 1, 5
• The dose can be increased to 800 mg three times daily if 400 mg provides insufficient relief, with a maximum daily dose of 3200 mg 1
• Administer with meals or milk to minimize gastrointestinal complaints 1
• Do not add muscle relaxants (such as cyclobenzaprine) routinely, as a high-quality randomized controlled trial demonstrated no additional benefit when cyclobenzaprine was added to ibuprofen for acute cervical strain 2

Non-Pharmacologic Management

Avoid cervical collar immobilization:

• International consensus guidelines recommend against cervical collar use by first aid providers due to growing evidence of complications and lack of benefit in patients without high-risk spinal injury criteria 3
• This patient has no indication for spinal immobilization (no neurological deficits, no severe mechanism, delayed symptom onset) 3

Encourage early mobilization:

• Active neck and shoulder exercises should be initiated early, as historical evidence shows that treatment excluding cervical collars and traction leads to better outcomes 6
• Patients should be encouraged to resume usual work and activities rather than prolonged rest 6

Expected Course and Follow-Up

• Most acute cervical strain improves within 7-8 weeks with conservative management, though approximately 50% may have some persistent symptoms at one year 3, 6
• The presence of interscapular or upper back pain is a negative prognostic factor for recovery 6
• Reassess within 2 weeks if symptoms worsen, new neurological symptoms develop, or pain becomes intractable despite appropriate therapy 4, 7

Important Caveats

• Acetaminophen is an alternative first-line agent if NSAIDs are contraindicated due to gastrointestinal, renal, or cardiovascular risk factors 5
• Opioids are not indicated for this mild pain presentation (3/10) and should be reserved for severe acute pain 5
• MRI findings in post-traumatic neck pain often overestimate injury severity (specificity 64-77%, false-positive rates 25-40%) and should not drive management in the absence of neurological symptoms 3
• Soft tissue injuries visible on MRI (disc herniation, cartilage plate clefts, facet hemarthrosis) are common after cervical trauma but do not necessarily correlate with clinical outcomes or require surgical intervention 3, 8