What causes pain in the neck and occipital region of the head?

Pain in Neck and Backside of Head

Direct Answer

Most neck and occipital head pain is mechanical/musculoskeletal in origin involving facet joints, intervertebral discs, muscles, or fascia, and resolves spontaneously without imaging unless red flag symptoms are present. 1, 2

Common Causes

Mechanical/Musculoskeletal (Most Common)

• Facet joint arthropathy causes localized mechanical pain that can radiate to the occipital region and upper trapezius area 3, 4
• Cervical degenerative disc disease is extremely common, affecting 53.9% of individuals aged 18-97, though it correlates poorly with symptoms in isolation 2, 4
• Cervical radiculopathy from herniated discs or osteophytes compressing nerve roots (annual incidence 83 per 100,000) can cause referred pain to the head, with 75-90% resolving with conservative therapy 3, 4
• Muscle pain and tension in the cervical region can refer pain to the occipital area through anatomical and physiological mechanisms 5

Cervicogenic Headache

• Pain originating from cervical spine structures (upper cervical zygapophysial joints, muscles, ligaments) can refer to frontal head regions and even the orbit through established neuroanatomical pathways 5
• Concomitant neck pain occurs in 73-90% of people with migraine or tension-type headache, with muscle pain and intensive, frequent neck pain associated with disturbing headache unresponsive to analgesics 6, 7

Serious Causes Requiring Urgent Evaluation

Life-Threatening Conditions

• Meningitis and cervical epidural abscess present with fever, neck stiffness, and altered mental status requiring immediate evaluation 2, 8
• Vertebral osteomyelitis or discitis presents with constitutional symptoms, elevated inflammatory markers (ESR, CRP, WBC), and history of IV drug use or immunosuppression 3, 4
• Metastatic disease to cervical vertebrae presents with intractable pain, constitutional symptoms, vertebral body tenderness, and history of malignancy 3, 4
• Cervical myelopathy from spinal cord compression requires differentiation from radiculopathy through careful neurological examination for weakness, sensory changes, and gait disturbance 3, 4
• Vertebral artery dissection and other vascular pathologies can cause neck and occipital pain 2

Red Flag Symptoms Requiring Immediate Imaging

Screen every patient for these indicators: 2, 3, 4

• Constitutional symptoms: fever, unexplained weight loss, night sweats
• Elevated inflammatory markers: ESR, CRP, WBC count
• History of malignancy or immunosuppression
• History of IV drug use
• Progressive neurological deficits: weakness, sensory changes, gait disturbance, bowel/bladder dysfunction
• Intractable pain despite appropriate conservative therapy
• Vertebral body tenderness on palpation

Diagnostic Algorithm

Acute Neck Pain (<6 weeks) WITHOUT Red Flags

• Do NOT order imaging - most cases resolve spontaneously with conservative management 1, 3, 4
• Pursue conservative treatment including rest, NSAIDs, physical therapy 4
• Approximately 50% will have residual or recurrent pain at 1 year, but this does not change initial management 4

Acute Neck Pain WITH Red Flags

• Immediately obtain MRI cervical spine without contrast - this is the preferred imaging modality for soft tissue abnormalities, disc herniation, nerve root impingement, inflammatory processes, infection, tumor, and vascular pathology 2, 3, 4

Chronic Neck Pain (>6-8 weeks) WITHOUT Red Flags

• Consider MRI cervical spine without contrast if persistent symptoms beyond 6-8 weeks of conservative therapy, progressive neurological deficits, or severe pain unresponsive to treatment 3, 4
• Document specific dermatomal distribution of pain and any associated sensory or motor deficits to localize affected nerve root level 3
• Perform Spurling's test - highly specific for nerve root compression from herniated cervical disc 3

Chronic Neck Pain WITH Red Flags

• Immediately obtain MRI cervical spine without contrast 3, 4

Critical Pitfalls to Avoid

• Do NOT order imaging immediately in absence of red flags - this leads to overdiagnosis of incidental degenerative changes that correlate poorly with symptoms, as 85% of asymptomatic individuals over 30 years have spondylotic changes 3, 4
• Do NOT interpret degenerative changes on imaging as causative without clinical correlation - a 10-year longitudinal MRI study showed 85% of patients with progression of cervical disc degeneration but only 34% developing symptoms 3
• Do NOT miss myelopathic signs that would indicate spinal cord compression requiring urgent surgical evaluation 3
• Do NOT confuse cervical radiculopathy with shoulder pathology - Spurling's test helps distinguish nerve root compression from other shoulder conditions 3