Neck pain - acute torticollis
Exam Tips
- In OSCEs, state that acute torticollis is a clinical diagnosis and routine imaging is unnecessary when history/exam are typical and no red flags exist.
- Always screen red flags explicitly: fever, weight loss, cancer history, night pain, trauma/osteoporosis risk, progressive neurological deficit, bowel/bladder dysfunction, immunosuppression, and infection risk.
- Spurling test helps support cervical radiculopathy if arm pain is reproduced, but avoid if possible neck injury, infection, malignancy, or rheumatoid instability is suspected.
- If neck pain follows dopamine-antagonist exposure, think acute dystonic reaction and treat promptly (withdraw trigger + anticholinergic therapy).
- Common exam trap: over-investigating uncomplicated cases; best-practice management is reassurance, early mobility, simple analgesia, and safety-netting.
Definition
Acute torticollis (wry neck) is an acquired, usually self-limiting syndrome of sudden unilateral neck pain with painful restriction of cervical movement and an abnormal head posture caused by muscle spasm. In UK primary care it is a clinical diagnosis, most often mechanical/non-specific, but clinicians must actively exclude serious secondary causes (for example infection, cervical cord disease, trauma, or malignancy).
Pathophysiology
Most cases are mechanical: minor facet joint irritation, paraspinal/SCM muscle strain, or awkward sustained posture triggers local inflammation and a reflex pain-spasm cycle, producing guarding, tilt, and reduced range of motion. Nociceptive input from cervical muscles and zygapophyseal joints amplifies segmental muscle hypertonia, so movement worsens pain and spasm. A smaller subgroup is secondary torticollis (for example acute disc prolapse, cervical radiculopathy/myelopathy, infection, or tumour). Drug-induced dystonic torticollis is a distinct mechanism related to dopamine-cholinergic imbalance in basal ganglia pathways after dopamine-antagonist exposure (for example metoclopramide, prochlorperazine, antipsychotics). See Figure: cervical muscle anatomy (sternocleidomastoid/trapezius) and cervical dermatome map in standard musculoskeletal/neurology texts.
Risk Factors
- Age 40-59 years
- Female sex
- Previous neck pain episodes
- Awkward or prolonged neck posture at work (office/computer work, manual labour, healthcare roles)
- Sedentary lifestyle and poor workstation ergonomics
- Sleep disturbance or inadequate neck support during sleep
- Psychological stress, anxiety, depression
- Smoking
- Obesity
- Trauma history
- Underlying rheumatological disease (for example rheumatoid arthritis)
Clinical Features
Symptoms
- Sudden severe unilateral neck pain, sometimes radiating to occiput, shoulder, or upper back
- Painful neck stiffness with inability to comfortably rotate or side-flex
- Sensation of cramp/spasm in neck muscles
- Possible associated headache
- History of recent awkward posture, prolonged positioning, exposure to cold, or minor unnoticed strain
Signs
- Abnormal head/neck posture (tilt or rotation) with protective splinting
- Reduced active and passive cervical range of motion due to pain
- Unilateral diffuse tenderness and palpable muscle spasm/trigger points
- Usually no focal neurological deficit in simple acute torticollis
- Red-flag signs requiring urgent assessment: fever, vertebral tenderness, progressive neurological deficits, gait disturbance, upper motor neurone signs (hyperreflexia/Babinski/clonus), severe night pain, unexplained weight loss, meningism
Investigations
Management
Lifestyle Modifications
- Reassure about usually benign and self-limiting course; encourage early gentle movement and normal activity as tolerated
- Avoid prolonged collar use and prolonged bed rest
- Short-term heat packs and simple neck mobility/stretching exercises
- Address ergonomics (screen height, chair support, load carrying symmetry) and sleep posture/pillow support
- Safety-net urgently for red flags (fever, worsening neurology, severe night pain, trauma history, cancer history)
Pharmacological Treatment
Simple analgesia (first-line)
- Paracetamol 1 g orally every 4-6 hours (max 4 g/day)
Check total daily dose from all products; caution in low body weight, frailty, or liver impairment/alcohol excess (consider lower maximum daily dose).
NSAID (if no contraindication, often with/after paracetamol)
- Ibuprofen 400 mg orally three times daily with food (max 2.4 g/day prescription)
- Naproxen 250-500 mg orally twice daily
Use lowest effective dose for shortest duration. Avoid/caution in peptic ulcer disease, CKD, heart failure, ischemic heart disease, anticoagulant use, pregnancy (especially 3rd trimester), and NSAID-exacerbated asthma. Consider gastroprotection (for example omeprazole 20 mg once daily) if GI risk.
Short-course weak opioid (rescue only when pain remains severe despite above)
- Codeine phosphate 30-60 mg orally every 4 hours as needed (max 240 mg/day)
Limit duration; counsel on constipation, nausea, sedation, driving impairment, and dependence risk. Avoid with significant respiratory depression; caution with other CNS depressants.
If acute drug-induced dystonic torticollis is suspected
- Procyclidine 5-10 mg IM or slow IV for acute reaction, then oral 5 mg three times daily for short course
- Alternative: Benztropine 1-2 mg IM/IV
Stop/review offending dopamine-antagonist drug. Monitor anticholinergic adverse effects (confusion, urinary retention, glaucoma risk), particularly in older adults.
Complications
- Occupational disability and short-term work absence
- Persistent or recurrent neck pain beyond the initial episode
- Psychological comorbidity, especially depression in acquired torticollis
- Missed serious pathology if red flags are not recognized early
Prognosis
Most acute torticollis improves within 48 hours and settles within 7-10 days. More broadly, acute neck pain often improves within 2 months, but recurrence or low-grade symptoms over the following year is common.
Sources & References
🏥BMJ Best Practice(1)
✅NICE Guidelines(1)
- Neck pain - acute torticollis[overview]