Stiff Neck

The most common causes of acute neck stiffness are benign and easily managed in general practice. However, this symptom causes disproportionate panic in parents of febrile children thanks to extensive media coverage of meningitis. This anxiety can spill over into adult illness behaviour, with the result that a troublesome but harmless symptom may be misinterpreted as the harbinger of serious pathology.

Published: 2nd August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • Acute Torticollis
  • Cervical Spondylosis
  • Viral URTI with Cervical Lymphadenitis
  • Whiplash Injury
  • Meningism Due to Systemic Infection (e.g. Pneumonia)

Occasional Diagnoses

  • Tension/Stress (Common, but Usually Causes an Ache or Muscle Tenderness Rather than Stiffness)
  • Other Forms of Arthritis (e.g. Rheumatoid [RA] and Ankylosing Spondylitis)
  • Abscess in the Neck
  • Functional Neurological Disorder
  • Intracerebral Haemorrhage
  • Cerebral Tumour

Rare Diagnoses

  • Meningitis
  • Vertebral Fracture
  • Bone Tumour (Primary or Secondary)
  • Atypical Infections: Tetanus, Leptospirosis, Sandfly Fever, Psittacosis
  • Brain Abscess

Ready reckoner

Key distinguishing features of the most common diagnoses

TorticollisCervical SpondylosisURTIWhiplashMeningism
Other SymptomsNoPossibleYesPossibleYes
Enlarged lymph NodesNoNoYesNoPossible
Neck AsymmetricalYesPossibleNoPossibleNo

Possible investigations

Likely: None.

Possible: FBC, Paul–Bunnell test, ESR/CRP, rheumatoid factor, HLA-B27.

Small Print: Bone biochemistry, X-ray cervical spine, bone scan, other hospital-based tests.

  • FBC and Paul–Bunnell: In unresolved or resistant URTI, check these parameters if glandular fever suspected.
  • ESR/CRP, rheumatoid factor and HLA-B27: Will help in the diagnosis of possible RA and ankylosing spondylitis in the young and middle-aged with unresolving neck stiffness.
  • Neck X-ray: For possible fracture (at hospital); of limited value in cervical spondylosis – symptoms do not correlate well with X-ray findings. May reveal serious bone pathology, but bone scan more useful for this.
  • Bone biochemistry: Consider this if bony secondaries or myeloma are possible diagnoses.
  • Hospital-based tests: These might include lumbar puncture (for meningitis) and scans for cerebral lesions.

Top Tips

  • Neck tenderness due to cervical lymphadenopathy in an URTI is infinitely more common than meningitis, but is often misreported as ‘neck stiffness’.
  • Only advise soft collars in the majority of stiff necks for a maximum of 48 hours. Though comfortable, they tend to delay resolution. Instead, suggest adequate analgesia, heat and mobilisation.
  • Warn patients with whiplash injury that symptoms may take many months to settle completely – this saves repeated futile and frustrating consultations.

Red Flags

  • Meningococcal petechiae are usually a late sign and can be missed unless the febrile child with a stiff neck is undressed and examined.
  • Pain and stiffness may be the only symptoms of vertebral fracture or subluxation, which can occur without cord involvement – significant trauma merits A&E referral.
  • Thunderclap headache preceding neck stiffness suggests subarachnoid haemorrhage – admit straight away.
  • Consider serious bony pathology if pain and stiffness are relentless and wake the patient at night – especially if there are other worrying symptoms, or the patient has a past history of carcinoma.
  • Pain onset in whiplash is usually delayed. Immediate onset may mean significant bony injury.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.