Treatment of Neck Spasms
For neck spasms, refer to a rehabilitation specialist (physiatrist) for comprehensive neuromusculoskeletal management, which should include physical therapy, range of motion exercises, and ergonomic modifications, with nerve-stabilizing agents (pregabalin, gabapentin, or duloxetine) as adjunctive pharmacologic treatment. 1, 2
Initial Assessment Required
Before initiating treatment, evaluate for "red flags" that require urgent workup: 2, 3
- Neurological deficits (myelopathy, radiculopathy with motor weakness)
- Constitutional symptoms (fever, weight loss, night sweats)
- History of malignancy, immunosuppression, or inflammatory arthritis
- Significant trauma
- Severe or progressive symptoms despite conservative care
If red flags are present, obtain cervical MRI without contrast before specialist referral. 2, 4 However, routine imaging is not indicated for uncomplicated neck spasms without these concerning features. 4
Core Treatment Strategy
Rehabilitation Management (First-Line)
Referral to a physiatrist is the cornerstone of treatment, as specialized rehabilitation significantly improves pain, disability, and range of motion. 1, 2 The rehabilitation program should include: 2
- Range of motion exercises to maintain flexibility and prevent stiffness
- Ergonomic modifications: position computer monitors at eye level, adjust chair height appropriately, avoid sustained static postures
- Regular breaks every 30-60 minutes during desk work or repetitive activities
- Targeted physical therapy to improve strength, mobility, and function
Pharmacologic Adjuncts
Nerve-stabilizing agents facilitate participation in physical therapy and improve spasm control. 1, 2 Prescribe one of the following: 1, 2
- Pregabalin
- Gabapentin
- Duloxetine
Muscle relaxants (cyclobenzaprine) may be used as adjuncts for acute muscle spasm associated with painful musculoskeletal conditions, but only for short periods (2-3 weeks maximum), as evidence for prolonged use is lacking. 5 Note that cyclobenzaprine is not effective for spasticity from neurological disease. 5
Advanced Treatment for Refractory Cases
For cervical dystonia or spasms that fail to respond to rehabilitation and nerve-stabilizing agents, refer to a specialist for botulinum toxin type A injections into affected muscles. 1, 2 Approved formulations include AboBoNT-A (Dysport), rimaBoNT-B (Myobloc), OnaBoNT-A (Botox), and incoBoNT-A (Xeomin). 2 This is particularly relevant for patients with history of head and neck cancer treatment, as cervical dystonia can result from neck dissection or radiation therapy. 1, 4, 6
What to Avoid
Do not prescribe cervical collars for chronic neck spasms, as they are associated with significant harm and can worsen outcomes. 2
Follow-Up and Reassessment
Evaluate response to ergonomic modifications and physical therapy at 4-6 weeks. 2 Most patients (75-90%) with neck pain achieve symptomatic relief with conservative non-operative therapy. 2, 3
When to Consider Surgical Referral
Refer to spine surgery only if: 2
- Cervical spondylotic myelopathy is present
- Severe, prolonged symptoms with low probability of improvement with non-operative measures
- Clinically significant motor deficits develop
Note that 70% of patients with mild cervical myelopathy maintain clinical gains after non-operative treatment for 3 years. 2
Special Considerations
For patients with history of head and neck cancer treatment, assess specifically for secondary cervical dystonia, which is characterized by painful dystonic spasms of cervical muscles caused by neck dissection, radiation, or both. 1, 4 These patients require the same rehabilitation-focused approach with potential escalation to botulinum toxin injections if conservative measures fail. 1, 6