Stiff Neck: Causes and Treatment
Most Common Cause
The vast majority of stiff neck cases are mechanical in origin, caused by muscle strain, cervical spondylosis, or minor soft tissue injury, and will resolve spontaneously within 2 months with conservative management. 1, 2
Primary Mechanical Causes
- Muscle strain and spasm from awkward sleeping positions or sustained postures represents the most frequent etiology, particularly in children and young adults where tissue strangulation in the C2-C3 or C3-C4 uncovertebral zones during sleep can cause acute torticollis 3
- Cervical radiculopathy from herniated disc or osteophyte compression is the primary mechanical neuropathic pain source 4
- Facet joint arthropathy causes localized mechanical pain that may be unilateral 4
- Cervical osteoarthritis with degenerative disc disease is common but correlates poorly with symptoms in isolation 5, 4
Critical "Red Flags" Requiring Urgent Evaluation
You must immediately pursue advanced imaging and workup if any of these are present:
- Constitutional symptoms: fever, unexplained weight loss, night sweats 4, 6
- Meningeal signs: stiff neck combined with headache suggests increased intracranial pressure or meningitis requiring lumbar puncture after neuroimaging 5
- Elevated inflammatory markers (ESR, CRP, WBC) warrant urgent MRI evaluation 4, 6
- Neurological deficits: weakness, sensory changes, gait disturbance, or myelopathic signs 4
- History of malignancy or immunosuppression 4, 6
- Intractable pain despite appropriate conservative therapy 4
- Vertebral body tenderness on palpation 4
Treatment Algorithm
For Acute Stiff Neck WITHOUT Red Flags (<6 weeks):
- No imaging is required initially - most cases resolve spontaneously 5, 4, 1
- Conservative management: NSAIDs (ibuprofen), activity modification, gentle range of motion exercises 6, 1
- Muscle relaxants have some evidence for acute neck pain associated with muscle spasm 1
- Exercise therapy appears beneficial and should be initiated early 1
- Reassess at 6-8 weeks - if symptoms persist, proceed to imaging 4
For Acute Stiff Neck WITH Red Flags:
- Obtain MRI cervical spine without contrast immediately - this is the preferred imaging modality for soft tissue abnormalities, inflammatory processes, infection, tumor, or vascular pathology 4, 6
- Check inflammatory markers (ESR, CRP) if not already done 4, 6
- If meningeal signs present (stiff neck with headache): perform neuroimaging first, then lumbar puncture to measure intracranial pressure and evaluate for meningitis; include Lyme and syphilis serology 5
For Chronic Stiff Neck (>12 weeks):
- MRI cervical spine without contrast is indicated for persistent symptoms beyond 6-8 weeks of conservative therapy, progressive neurological deficits, or severe pain unresponsive to treatment 4
- Continue conservative management with physical therapy and NSAIDs if MRI reveals no serious pathology 6
- Refer to specialist if MRI reveals significant pathology 6
Important Pitfalls to Avoid
- Do not order imaging immediately in the absence of red flags - this leads to overdiagnosis of incidental degenerative changes present in 85% of asymptomatic individuals over 30 years 4
- Do not assume degenerative changes on imaging are causative without clinical correlation - spondylotic changes correlate poorly with symptoms 5, 4
- Do not miss referred pain from shoulder impingement - chronic lower neck pain near the superomedial scapula may be from shoulder pathology, diagnosed by positive impingement sign and relieved by subacromial injection 7
- Do not dismiss elevated CRP - this represents a significant red flag requiring MRI evaluation even if initial X-rays show only mild degenerative changes 6