Head Neck Shoulder Pain | Information and Treatments

Dr Mark Miller FRCA
Consultant Anaesthetics and Pain Management
Royal Shrewsbury Hospital and Shropshire Nuffield Hospital.
Born 1965, Edinburgh. Qualified 1990 MBChB Manchester University. Acquired membership of the Royal College of Anaesthetists in 1997.

Head, Neck and Shoulder Pain

Neck Pain
As with all pain clinic assessments of paramount importance is to exclude sinister causes for the pain. These include cancer pains.

If such a cause is suspected or found then you will be referred to an appropriate physician. This can be subcategorised very much like pain arising from the lower back with pain either being limited to the neck or present also in any combination of head, arms, shoulders and hands.

Another way of looking at the origin of neck pain is that it may arise from the neck or cervical vertebral bones, the spinal ligaments or the spinal musculature. Some will also argue that superficial neck pain is a sign of pain arising from a cervical intervertebral disc. This is discogenic pain. There is a theory abounding that discogenic pain may be the main cause of what eventually becomes fibromyalgia or widespread body pain.

Pain limited to the neck

The cervical intervertebral joints are prone to degenerative or arthritic changes much the same as any other joint. The arthritic changes may also be inflammatory as in rheumatoid arthritis or ankylosing spondylitis.

This latter disease is an inherited condition where painful inflammation in the spine is eventually replaced by painless fusion of the vertebral bones. The cervical facet joints can be the source of neck pain although they are less recognised as being so in most pain clinics. This is probably because it is much more difficult to inject into them compared to the thoracic and lumbar facet joints so fewer pain doctors undertake this type of work. The risks are also greater with the underlying spinal cord and the vertebral arteries close by. Instead they usually prescribe painkilling drugs and concentrate on treating the superficial trigger and tender points with steroid and even Botox injections. TENS machines are also useful for some patients as are the topical NSAID and capsaicin creams.

Pain in the neck and arms
Whiplash injury with ligament and joint damage, slipped discs in the neck, degenerative arthritis in the neck and muscular neck injury with muscle spasm can all lead to symptoms in the neck, head, shoulders and arms. As a result, differentiating between an individual’s symptoms to decide where there pain is coming from can be extremely difficult. In addition, a patient may concentrate on neck and arm pain when actually they hurt all over and actually have fibromylagia or other such chronic pain syndrome.

Slipped neck discs are common and may lead to shooting or aching pains in specific parts of the head, arms and specific fingers. Associated symptoms may include weakness in the upper limbs, pins and needles (parasthesiae or dysaesthesiae if painful) or even numbness. Arthritic neck bones may also compress nerves and give the same symptoms. If associated symptoms are severe, bowel and bladder function are affected or the MRI scan suggests an unstable spine with spondylolisthesis then referral to a spinal surgeon may be necessary if one has not already been seen.

neck pain Nerves from the neck form the Brachial plexus which goes on to give the nerve supply to the arms, hands and upper chest wall. If this is damaged or invaded by cancer then it will also give neuropathic symptoms and signs.

Treatments
As with caudal and lumbar epidurals being effective for sciatica so cervical epidurals can be effective for slipped neck discs causing arm and hand pain. The principle is the same as well with injection of steroid but this time even more care is required because the spinal cord lies beneath.

Cervical epidurals can be repeated 3-4 times a year if necessary but they should give good lengths of time of pain relief. Others find TENS useful for their pains. Muscle spasms in the shoulders are often responsive to Botox injections if they do not respond to simple acupuncture or trigger point injections with steroid.

Headache
Headaches can be looked at as being caused by problems in the head itself or resulting from problems in the neck and shoulders being referred to the head.

Migraine – most patients with migraine are treated successfully by their G.P.s and neurologists and rarely come to the pain clinic as a primary referral. Symptoms include changes in mood with one-sided headache, sensitivity to light, visual disturbance and sometimes nausea and vomiting. These headaches can last for 4 to 72 hours. Less commonly they are associated with an aura which describes associated visual disturbances or even episodes of speech impediment or weakness. Treatment is with specific drugs e.g. migraleve (sumatriptan)

Cervicogenic Headache – secondary to pain from the neck. Muscle spasm leads to irritation of the greater occipital nerves and pain on one or both sides of the head felt only as far forward as the forehead. Greater occipital nerve block with steroid is often useful.

Tension Headache – lasts 30 minutes to 7 days at a time. These are felt on both sides of the head and are distinguished from migraine as not being associated with nausea or vomiting or light or sound sensitivity.

Cluster Headache – This is severe one-sided pain affecting the area of the eye and above and behind it. The pain lasts for 15 minutes to 3 hours. Attacks occur from one every other day to 8 a day and are associated with symptoms such as nasal congestion, excessive tears, runny nose, sweating, and swelling all on the same side as the headache.
Attacks occur in clusters lasting 4 to 10 weeks. These are interspersed by pain free periods of months or years.

Treatment is mainly with drugs such as migraleve and abstinence from causal factors e.g. alcohol.
If the headaches occur 15 to 20 times a day and last for only 3-15 minutes then this is termed chronic paroxysmal hemicrania and the drug indomethacin, an NSAID, is usually successful.

Analgesic headache – Large doses of aspirin, paracetamol or codeine used to treat headache can actually aggravate headache themselves. The same is true with sudden withdrawal form migraleve (sumatriptan). Therefore these painkillers should not be taken everyday for headaches.