Head and neck
Stiff necks, and the band of pressure around the head that so often comes with them. They share a page because they share a mechanism, and because treating one without asking about the other is how both tend to get missed.
Neck pain ranks among the highest conditions worldwide for years lived with disability, and headache is not far behind it. Between them they account for a large slice of what comes through my door, and for a large slice of the advice people arrive with that the research does not support.
On this page
Neck pain is pain in the region between the base of the skull and the top of the shoulder blades, often with reduced movement and referral into the head, shoulder or arm. As with the lower back, most cases are non-specific, meaning no single structure can be isolated as the source.
Non-specific is a description rather than a shrug as it tells you the pain is coming from the region instead of from one identifiable structure, and it is the reason that treatment aimed at the whole area does better than treatment aimed at one joint.
Most neck pain is a neck that has been asked to hold still for too long at a load it was never prepared for. Sustained positions, very little variation through the day, poor sleep and a spell of higher stress or workload combine far more often than any single incident does.
People usually arrive expecting to be told which vertebra has gone out of place. The more useful question is what the neck has been asked to do for the past three weeks, and how much variety there has been in it.
Holding one position for eight hours is sustained low-level work, which is harder than it sounds. The muscles that fatigue are the ones that have never been given anything to build capacity with. That is why the treatment involves loading the upper back rather than stretching the part that hurts.
Probably not in the way you have been told. A 2024 scoping review went looking for the original evidence behind the plumb-line standard posture used in assessment for decades and could not find it properly sourced. A systematic review of text neck across 1,067 participants found no association with the onset of neck pain.
Sedentary time is not innocent, though. A 2025 systematic review and meta-analysis found screen-based sedentary behaviour to be a meaningful risk factor for neck pain, with prolonged phone use carrying the greatest risk. Television viewing was not identified as a risk, which is a clue as to what is doing the damage.
So the shape you hold turns out to be a weak predictor of pain. How long you hold it, and how little you vary it, is a much better one.
Yes. Structures in the upper neck share nerve pathways with the head, so neck problems can produce and sustain headaches. Tension-type headache commonly comes with tenderness in the neck and shoulder muscles, and manual therapy aimed at the neck and upper back has matched preventive medication for headache frequency in reviewed trials.
Where this gets stretched is the jump from can to always. A headache with neck pain present is not automatically a headache caused by the neck, and migraine in particular has a relationship with the neck that I have given a separate page.
The assessment is what usually distinguishes them: cervical range of motion, provocation testing, and whether your neck bothers you between headaches or only alongside them.
Read more: migraine and cervicogenic headache
Tension-type headache is a bilateral, pressing or tightening head pain of mild to moderate intensity that does not worsen with routine physical activity. It is the commonest headache disorder and it frequently comes with tenderness in the neck and shoulder muscles. Only around 20 per cent of people with the chronic form seek care.
The word tension sends people hunting for one tight muscle but what the presentation usually reflects is a system under sustained load: long static hours, poor sleep, a difficult stretch at work, little aerobic activity, and a neck that has not been asked to do anything varied in weeks. The good news is that all of that is treatable.
Tension-type headache is usually on both sides, pressing or tightening, mild to moderate, and it does not get worse with ordinary physical activity. Migraine is usually one sided, throbbing, moderate to severe, made worse by routine activity, and often comes with nausea or sensitivity to light and sound.
Plenty of people have both, which is where self-diagnosis comes unstuck. A four week diary can often figure it out faster than any single consultation, because in headache work the pattern is often the diagnosis.
Migraine is managed differently and has a page of its own, because the current evidence gives a clearer picture than most sites are working from.
They can. Frequent use of simple painkillers can drive medication-overuse headache, where the treatment starts feeding the problem. Acute headache medication is generally kept to around two days a week to avoid it. If you are reaching for something more often than that, raise it with your doctor or pharmacist.
I mention it because it is one of the more useful things a musculoskeletal practitioner can flag, and it almost never gets said. It is also important to note that it is also not my call. I will not tell you to stop or change anything you are taking without first consulting with your GP or specialist.
What I will ask is that you count your medication days religiously for four weeks. That is where we will see the pattern emerge as very few people spot it without writing it down.
Cervical manipulation is a well-established technique with a good safety record when it follows proper screening. That screening happens at every assessment, before any technique is chosen. If anything in your history or examination points towards a vascular cause, we do not manipulate and you get referred.
I would rather set that out plainly than leave the question hanging, because it is a fair thing to ask.
Screening covers history, neurological testing, blood pressure where the history calls for it, and specific questioning about symptoms that point elsewhere: sudden severe neck or head pain with dizziness, visual disturbance, difficulty speaking or facial numbness. Anyone reporting those is sent for same-day medical assessment instead of being treated.
Manipulation is also not compulsory. Mobilisation, soft tissue work and loading produce comparable results, so if you would rather not be manipulated, say so at the first visit and the plan gets tweaked without it.
Most episodes settle over a few weeks. What tends to predict a longer course is low variation in daily positions, limited upper body strength, poor sleep and a sustained spell of stress. The good news is that all four of those can be addressed.
The point of a consultation is not only to settle this episode. It is to leave you with more capacity than you had before it started, because that is what changes the pattern of recurrence.
How I work
Care runs in three steps: working out what is driving the pain, loading the neck and upper back back up to tolerance, and returning to normal activity without negotiating around it. Evidence across most neck pain presentations supports manual therapy combined with exercise rather than either given on its own.
01
We work out what the neck has been doing, what the headache pattern looks like, and which of the two is driving the other. That includes a proper headache history, because a headache treated as a neck problem when it is not one wastes a good deal of time.
02
Cervical and thoracic manipulation and mobilisation, dry needling, ischaemic compression to the upper trapezius, levator scapulae and suboccipital group, and IASTM are all part of this step. A 2025 systematic review with meta-analysis supports cervical joint mobilisation for pain and disability in non-specific neck pain, and guidelines support thoracic manipulation, range of motion work and upper back and arm strengthening where movement is restricted.
Alongside that, deep neck flexor and scapular loading as well as stretches to promote movement throughout the day.
03
Then we change what caused it, which usually means the total amount of static time rather than the shape of it, and build capacity so that the same working week costs you less. For most of my desk-based patients the fix is nearly always in the structure of the day rather than in the chair or the desk setup.
There are four things you can do this week. Break the day up with a minute of movement every hour instead of one long stretch session. Load your upper back with rows and carries. Set your screen once and stop worrying about the exact angle. And keep a headache diary for four weeks if headache is part of the picture.
Chin nods, gentle rotations and shoulder blade work, a minute every hour. Frequency is the important part here, not intensity. Ten minutes at six o'clock does not undo eight hours of stillness.
Rows and carries do more for necks than stretching does. Stretching buys about twenty minutes of relief whereas strength changes what the neck can tolerate by Thursday afternoon.
Top of the screen near eye level, then stop thinking about it. The exact angle is not what is making you sore. How long you stay in it is.
Headache days, medication days, sleep, stress are all patterns that show up quickly and it turns something vague into something workable. Bring your headache diary with you to the assessment and we can go through it together to find the patterns.
Green
Soreness during or shortly after activity that settles within 24 hours and is not climbing session on session. Carry on. This is what adaptation feels like.
Amber
Soreness still up after 24 hours, or creeping upward week on week. Hold the dose where it is for a week instead of increasing it. Do not stop.
Red
New weakness or numbness in an arm, a headache unlike any you have had before, or any of the symptoms in the section below. Stop and get assessed.
Go to an emergency department the same day for a sudden severe headache unlike any before, particularly with neck stiffness, fever, confusion or visual loss, or for new neurological symptoms after a head or neck injury. See a doctor promptly for a first severe headache after 50, or a clear change in a long-standing pattern.
See a doctor promptly too for new or worsening weakness, numbness or loss of a reflex in an arm, for unexplained weight loss, night sweats or fever alongside neck pain, for pain that is unrelenting at night and unrelated to position, or after any significant trauma.
All of this is uncommon but it is set out here so that you know what does need urgent attention, which makes it easier to stop worrying about the rest.
Although I have an extensive knowledge of pain pharmacology, questions about medication are better aimed at your doctor or pharmacist rather than at me. I am not allowed to script any medication.
Next step
If your neck has been sore for weeks, or you are getting headaches often enough to plan around them, the first consultation is where we work out what is driving it. It runs 45 to 60 minutes and no referral is needed.
Phone 031 035 1165 · WhatsApp 064 820 5203 · A1a Meyrickton Park, 2 Meyrickton Pl, St Helier, Hillcrest, 3610
This page is general information and is not a substitute for personalised medical advice. Always consult a healthcare provider about your specific condition.
