Background
A 42-year-old professional and mother of two teenage boys presented with persistent neck and shoulder pain, along with intermittent headaches that had been troubling her for six months. The pain fluctuated, often worsening during high-stress workweeks and easing slightly during weekends. She had no clear history of injury. She tried stretching routines she found on social media and booked a massage, which provided temporary relief for about a week. However, her headaches and neck pain kept returning. At this point, she was frustrated and worried that stress and work demands would keep her trapped in a cycle of recurring pain.
Why Stress Can Drive Pain
Chronic stress is a commonly underappreciated driver of neck and back pain. While many patients expect a “structural” explanation for pain. Our biomedical culture circles around a structural cause most of the time with scans and exams. However research shows that stress can amplify pain through several ways. Upper trapezius or shoulder muscle tension arises from chronic sympathetic nervous system activation resulting in a sustained muscle contraction. The pain cycle gets reinforced with worrying about the pain and how it is interfering with quality of life. This also can heighten muscle tone and pain sensitivity [1,2,3,4,5].
Stress can influence pain for the good or bad. It can either reduce pain (stress-induced analgesia or SIA) or make pain worse (stress-induced hyperalgesia or SIH). The endogenous opioid system, which includes natural opioid receptors and peptides in the brain and body, plays a key role in these stress-induced changes in pain However, with repeated or chronic stress, the opioid system can become dysregulated, leading to SIH where pain sensitivity is increased.[7,8]
Examination Findings
During her assessment, several important findings emerged. Movement and posture assessment revealed forward head posture and rounded shoulders. Repeated low-load cervical retraction improved symptoms, suggesting a mechanical component to her pain. An upper cervical exam also revealed hypomobile segments. She had significant muscle tenderness in the suboccipital and occipital regions which are at the base of head in the back. Deep palpation reproduced some right side head pain. Her right sternocleidomastoid muscle (side of neck) presented with a latent trigger point and produced eye pain when squeezing the muscle There was significant muscle tautness in the upper shoulder muscles. A Stress and anxiety screening showed high work and family related stress. She felt better on the weekends and amplified pain when work demanded more of her time.
Treatment Approach
Her care plan targeted both the physical and cognitive factors of pain. Soft tissue mobilization and gentle joint techniques to reduce cervical muscle tension and upper cervical mobility. Exercises that addressed upper cervical mobility, thoracic and scapular strengthening, and thoracic mobility work to correct forward head posture. She adjusted how she sat at work to reduce upper cervical tension.
We implemented some Cognitive Functional Coaching, a smaller version of full Cognitive Functional Therapy, to help her to recognize how stress and anxiety amplified pain signals, reframing flare-ups as safe but sensitized responses that will go away. Stress response reduction strategies that include breathing drills such as the 4-7-8 technique to use in the moment of increasing tension. She also incorporated movement breaks during work. She also began her day earlier to carve out time for herself in the morning before the kids woke.
Outcome
Within three weeks, she reported fewer headaches, reduced daily pain, and improved posture awareness. By six weeks, she was able to work full days without flare-ups, and she gained confidence in her ability to manage stressful periods without triggering pain episodes.
Key Takeaways
Chronic stress and heightened anxiety can be powerful but overlooked drivers of musculoskeletal pain and headaches. Postural strain and cervical spine mobility limitations add a mechanical layer to pain and headaches. However many clinicians focus mostly on the mechanical problem while under appreciating the role of stress as a pain contributor. If repeated neck manipulations or massages are not providing lasting and demonstrated improvement over time, then perhaps a chronic stress issue could be influencing the pain.
References
- Tavakkoli, Maryam, and Fatemeh Bahrpeyma. “Elastic Modulus of Suboccipital Muscles, Cervical Range of Motion, and Forward Head Posture in Cervicogenic Headache.” Archives of Bone and Joint Surgery, vol. 11, no. 10, 2023, pp. 589-596
- Weatherall, Mark W. “Muscle Contraction Tension Headache.” StatPearls, StatPearls Publishing, Dec. 2024.
- Hassinger, H., et al. “EHMTI-0360. Chronic Sympathetic Activation in Migraine Headache: Unique to Migraine or Common to Sympathetic Nervous System Disorders?” The Journal of Headache and Pain, vol. 15, suppl. 1, 2014, article C39.
- Weston, Eric B., et al. “Cognitive dissonance increases spine loading in the neck and low back.” Ergonomics 66.12 (2023): 2133-2147.
- Wiech K, Tracey I. The influence of negative emotions on pain: behavioral effects and neural mechanisms. Neuroimage. 2009;47(3):987-994.
- Fernández-de-Las-Peñas, C., Cuadrado, M. L., & Pareja, J. A. (2007). Myofascial trigger points, neck mobility, and forward head posture in tension-type headache patients. Cephalalgia, 27(5), 445–450.
- Ferdousi, Mehnaz, and David P. Finn. “Stress-induced modulation of pain: role of the endogenous opioid system.” Progress in brain research 239 (2018): 121-177.
- Li, Xiaoyun, and Li Hu. “The role of stress regulation on neural plasticity in pain chronification.” Neural plasticity 2016.1 (2016): 6402942.
