Can hypertension (high blood pressure) cause neck pain?

Can Hypertension Cause Neck Pain?

Hypertension does not typically cause neck pain in most patients, as hypertension is usually asymptomatic; however, neck pain can be a rare presenting symptom of malignant hypertension with severe end-organ damage, or conversely, chronic neck pain from cervical spondylosis may contribute to secondary hypertension through sympathetic nervous system activation. 1, 2, 3

Understanding the Relationship

Hypertension is Usually Asymptomatic

• The International Society of Hypertension explicitly states that patients with hypertension are often asymptomatic, and when symptoms do occur, they typically suggest secondary hypertension or hypertensive complications requiring further investigation 1
• Common symptoms that may occur with severe hypertension include headaches, visual disturbances, chest pain, shortness of breath, and dizziness—but neck pain is not listed among the typical manifestations 1, 4, 5

When Neck Pain May Indicate Hypertensive Emergency

If neck pain occurs with severe hypertension, consider malignant hypertension with raised intracranial pressure as a rare but serious cause. 2

• A case report documented neck pain as the presenting symptom in malignant hypertension, with the mechanism potentially being incipient tonsillar herniation of the cerebellum caused by raised intracranial pressure 2
• Red flag symptoms requiring immediate evaluation include: neck pain accompanied by headache, visual disturbances, confusion, altered mental status, seizures, or other neurological symptoms suggesting hypertensive encephalopathy 1, 4, 5
• The European Society of Cardiology recommends immediate assessment for hypertensive emergency when neurological symptoms are present, as these indicate acute hypertension-mediated organ damage 6, 4

The Reverse Relationship: Cervical Pathology Causing Hypertension

Chronic neck pain from cervical spondylosis may actually cause secondary hypertension rather than the reverse. 3

• Stimulation of sympathetic nerve fibers in pathologically degenerative cervical discs can produce sympathetic excitation and induce a sympathetic reflex, potentially causing hypertension 3
• Chronic neck pain may contribute to hypertension development through sympathetic arousal and failure of normal homeostatic pain regulatory mechanisms 3
• Two patients with cervical spondylosis and concomitant hypertension experienced resolution of both conditions after anterior cervical discectomy and fusion, suggesting cervical spondylosis may be an underrecognized cause of secondary hypertension 3

Neck Pain with Hypotension (Not Hypertension)

• Paradoxically, neck pain in a characteristic "coathanger" distribution (suboccipital and paracervical regions) is strongly associated with orthostatic hypotension in autonomic failure, not hypertension 7
• This neck pain occurs in 93% of patients with pure autonomic failure and 51% with multiple system atrophy, and is relieved by sitting or lying flat 7
• The pain is related to the degree of orthostatic blood pressure fall, representing muscle ischemia from inadequate perfusion during upright posture 7

Clinical Approach Algorithm

Step 1: Assess Blood Pressure Severity and Symptoms

• Measure blood pressure properly: patient seated quietly for 5 minutes, obtain at least 2 measurements 1
• If BP ≥180/120 mmHg with neck pain PLUS any of the following, treat as hypertensive emergency: 1, 6, 4, 5
  • Headache, visual changes, confusion, or altered mental status
  • Focal neurological deficits or seizures
  • Chest pain or shortness of breath
  • Nausea, vomiting, or other signs of raised intracranial pressure

Step 2: Emergency Evaluation if Red Flags Present

• Obtain immediate laboratory analysis: hemoglobin, platelet count, creatinine, sodium, potassium, LDH, haptoglobin, quantitative urinalysis 6, 5
• Perform ECG and fundoscopy to assess for acute hypertension-mediated organ damage 6, 5
• Obtain brain MRI if unsteadiness or neurological symptoms present, as these significantly increase likelihood of intracranial pathology including hypertensive encephalopathy or posterior reversible encephalopathy syndrome (PRES) 6
• Do not delay imaging while attempting blood pressure reduction, as identifying underlying pathology guides appropriate BP targets 6

Step 3: If No Emergency Features, Evaluate for Alternative Causes

Most neck pain with elevated BP is coincidental or represents cervical pathology contributing to secondary hypertension, not hypertension causing neck pain. 1, 3

• Obtain cervical spine imaging (radiographs initially, MRI if radiculopathy present) to evaluate for cervical spondylosis, disc disease, or other mechanical causes 1
• Consider secondary hypertension workup if cervical pathology identified, as this may be contributing to BP elevation through sympathetic activation 3
• Evaluate for obstructive sleep apnea if neck circumference >40 cm, as this is a common secondary cause of hypertension 1

Step 4: Management Based on Findings

• If hypertensive emergency confirmed: Initiate IV antihypertensive therapy in ICU setting, reduce mean arterial pressure by 20-25% over first hour, then to 160/110-100 mmHg over next 2-6 hours 6, 5
• If cervical spondylosis with refractory symptoms: Consider anterior cervical discectomy and fusion, which may improve both neck pain and blood pressure control 3
• If asymptomatic hypertension with incidental neck pain: Treat as separate conditions—initiate lifestyle modifications and antihypertensive therapy per standard guidelines, and manage neck pain with conservative measures 8

Critical Pitfalls to Avoid

• Do not dismiss neck pain as "benign" musculoskeletal pain in the setting of severe hypertension with any neurological symptoms, as this may represent evolving hypertensive encephalopathy requiring immediate intervention 6, 4
• Do not rely solely on neurological examination, as absence of focal deficits does not exclude hypertensive encephalopathy, PRES, or early stroke 6
• Do not assume hypertension is causing neck pain without considering the reverse relationship—cervical pathology may be driving secondary hypertension through sympathetic activation 3
• Do not rapidly lower blood pressure without imaging in patients with neurological symptoms, as excessive BP reduction can cause organ underperfusion and cerebral infarction 5