Cervicalgia in Pregnancy: Causes, Posture and Relief

Pregnancy represents one of the periods of greatest physiological, anatomical, and biomechanical transformation in a woman’s life. During the three trimesters of gestation, the female body undergoes a series of adaptations necessary to accommodate and support fetal growth. However, these rapid changes can alter the delicate musculoskeletal balance, leading to the onset of painful disorders. Neck pain in pregnancy is one of the most widespread problems and, although often overshadowed by the more well-known low back pain, it can significantly impair the pregnant woman’s quality of life. Pain in the cervical spine, frequently accompanied by muscle stiffness, tension headaches, and functional limitation, requires a precise clinical assessment and a targeted therapeutic approach, taking into account the specific contraindications related to pregnancy. The aim of this article is to thoroughly analyze the causes, risk factors, postural alterations, and physiotherapeutic prevention and treatment strategies for managing neck pain during gestation, always emphasizing the importance of relying on your doctor or physical therapist for a personalized evaluation.

Anatomy and Physiology: The Causes of Neck Pain in Pregnancy

Cervicalgia in pregnancy is neck pain caused by postural changes, hormonal effects, and increased upper body strain during gestation. To fully understand the etiology of cervical pain during gestation, it is essential to analyze the systemic and structural modifications that occur in the maternal body. The vertebral column functions as an integrated biomechanical unit; therefore, an alteration in one region (such as the pelvis or lumbar spine) inevitably affects the segments above, reaching the cervical spine and the skull.

The Role of Hormonal Changes

From the very first weeks of gestation, the endocrine system undergoes radical changes. The hormone relaxin, produced by the corpus luteum and subsequently by the placenta, plays a crucial role. Its main function is to remodel collagen, increasing the laxity of pelvic ligaments to facilitate the passage of the fetus during childbirth (Borg-Stein et al., 2015). However, relaxin’s action is systemic and not limited to the pelvis alone. It acts on all joints of the body, including the cervical facet joints and the longitudinal ligaments of the vertebral column. This generalized joint hypermobility reduces the passive stability of the cervical spine, forcing the deep stabilizing muscles (such as the long muscles of the neck and head) and superficial muscles (trapezius, sternocleidomastoid) into continuous compensatory work to maintain head alignment. This constant muscular overload is one of the primary causes of fatigue and myofascial pain.

Biomechanical Alterations and Shift in Center of Gravity

With the increase in uterine volume and weight, the woman’s center of gravity progressively shifts forward and downward. To compensate for this shift and maintain bipedal balance without falling forward, the body implements a series of chain postural compensations (Katonis et al., 2011). Initially, there is an accentuation of lumbar lordosis and an anterior pelvic tilt. To balance the lumbar hyperlordosis, the thoracic spine increases its physiological kyphosis, leading to anterior shoulder posture (shoulders curved forward). Consequently, to maintain a horizontal gaze, the cervical spine is forced to accentuate its lordosis, adopting a posture of hyperextension of the upper cervical spine and flexion of the lower cervical spine. This posture, known as “forward head posture,” drastically alters neck biomechanics. The weight of the head, which in a neutral position places about 5-6 kg on the cervical structures, can feel like 15-20 kg on the lower cervical vertebrae due to the unfavorable lever arm, generating disc compression and significant tensile stress on the posterior neck muscles.

Increased Body Weight and Breast Changes

A further biomechanical factor of extreme relevance is the increase in breast volume and weight, as they prepare for future lactation. This anterior weight gain at the thoracic level significantly contributes to anterior shoulder posture and increased thoracic kyphosis. The pectoral muscles tend to shorten and retract, while the interscapular muscles (rhomboids and middle/lower trapezius) are stretched and weakened. This muscular dysfunction, defined as upper crossed syndrome, results in continuous traction on the cervical and nuchal insertions, promoting the onset of myofascial trigger points and referred pain at the base of the skull and along the neck.

Risk Factors and INAIL Data on Neck Pain in Pregnancy

In addition to intrinsic physiological changes, the onset of neck pain is strongly influenced by lifestyle, postural habits, and, in particular, the pregnant woman’s work activity. The interaction between bodily changes and the external environment determines the level of risk of developing musculoskeletal disorders.

The Impact of Work Activity

Maintaining prolonged static postures or performing repetitive movements of the upper limbs represent primary risk factors. During pregnancy, the reduced load tolerance of soft tissues makes workers more vulnerable to repeated microtraumas. The Consolidated Law on Health and Safety at Work (Legislative Decree 81/08) and subsequent guidelines for maternity protection pay particular attention to the risk of biomechanical overload. It is essential that the workstation is adapted to the worker’s morphological changes, ensuring frequent breaks and postural variations.

INAIL Data and At-Risk Professional Categories

Statistics and annual reports from INAIL (National Institute for Insurance against Accidents at Work) highlight how musculoskeletal disorders, including neck pain, are among the main causes of absence from work and requests for early maternity leave in specific professional categories. Although aggregated data often include low back pain as the predominant symptom, affections of the cervico-scapular region show a significant incidence in sectors requiring intensive use of visual display units or specific physical exertion.

Psychosocial Factors and Stress

The role of psychosocial factors should not be underestimated. Pregnancy can be a period of emotional vulnerability, anxiety about childbirth, and stress related to life changes. Scientific literature (Gouveia et al., 2018) demonstrates a strong correlation between psychological stress and increased muscle tone in the shoulder girdle and neck. Stress induces apical and superficial breathing, which overactivates accessory respiratory muscles (scalenes, sternocleidomastoid), which insert precisely on the cervical vertebrae, generating further stiffness and pain.

Symptomatology and Differential Diagnosis

The clinical picture of neck pain in pregnancy can vary considerably from person to person, presenting with nuances ranging from mild occasional discomfort to acute and debilitating pain. Correct symptom identification is the first step towards an adequate clinical assessment, which must always be performed by your doctor or physical therapist.

Typical Symptoms and Clinical Manifestations

In most cases, the pain is mechanical-postural or myofascial in nature. The most frequently reported symptoms include:

• Localized pain: Sensation of heaviness, tension, or burning at the base of the neck, extending towards the shoulders (trapezius muscle) or between the shoulder blades.
• Joint stiffness: Difficulty and limitation in head rotation, flexion, or extension movements, particularly evident upon waking or after prolonged static postures.
• Cervicogenic or tension headache: Pain originating from the suboccipital region (base of the skull) and radiating towards the forehead, temples, or behind the eyes, often described as a “band around the head.”
• Referred pain: Dull discomfort that may radiate down the arm, without, however, following a precise neurological dermatome, caused by the presence of active trigger points in the cervical musculature.

When to Consult Your Doctor or physical therapist: Red Flags

Although most episodes of neck pain are benign, it is imperative to rule out more serious pathologies. During pregnancy, some medical conditions can manifest with similar or overlapping symptoms. It is crucial to promptly consult your doctor or physical therapist if the so-called “warning signs” (Red Flags) appear.

The Importance of an Accurate Clinical Evaluation

Diagnosis is predominantly clinical. Your doctor or physical therapist will proceed with a detailed anamnesis and an accurate physical examination. During pregnancy, the use of imaging diagnostics (such as X-rays) is generally contraindicated to avoid exposing the fetus to ionizing radiation. Magnetic resonance imaging (MRI) may be considered only in cases of absolute necessity and under strict medical supervision. Therefore, the clinical skill of the healthcare professional in evaluating mobility, strength, reflexes, and soft tissue palpation becomes the primary diagnostic tool.

Prevention and Daily Management of Neck Pain in Pregnancy

Optimal management of neck pain begins with prevention and modification of daily habits. Adopting correct ergonomic and behavioral strategies is essential to minimize mechanical stress on vertebral structures throughout the nine months of gestation.

Ergonomics at Work and at Home

Adapting the surrounding environment to the new needs of the maternal body is a priority. For those who work in an office or spend many hours sitting, it is advisable to follow precise ergonomic rules:

• Chair adjustment: Use a chair with good lumbar support. As lumbar lordosis increases, an additional cushion at the lower back can help keep the spine aligned, preventing the collapse into thoracic kyphosis and the consequent forward neck posture. Feet should rest firmly on the floor or on a footrest, with knees at an angle of approximately 90-100 degrees.
• Monitor positioning: The top edge of the computer screen should be exactly at eye level. This prevents continuous downward head flexion. The distance between the eyes and the monitor should be about 50-70 cm.
• Use of supports: If using a laptop, the use of a stand to elevate it and the use of an external keyboard and mouse are strongly recommended. Arms should be supported by chair armrests or the desk, with elbows flexed at 90 degrees, to avoid overloading the trapezius muscles.
• Active breaks: It is essential to interrupt static posture every 45-60 minutes. Standing up, walking for a few minutes, and performing light shoulder and neck loosening movements promotes blood circulation and prevents local muscle ischemia.

Positions for Night Rest

Sleep is often disturbed during pregnancy, and an incorrect posture in bed can exacerbate cervical symptoms. As gestation progresses, the supine position (on the back) is not recommended to avoid compression of the inferior vena cava by the gravid uterus. The recommended position is the left lateral decubitus (on the left side) (Pennick et al., 2013). To protect the cervical spine in this position, the choice of pillow is crucial:

• The pillow must exactly fill the space between the ear and the shoulder, keeping the cervical spine aligned with the rest of the vertebral column. A pillow that is too high will cause upward lateral flexion, while one that is too low will cause downward flexion, both situations generating joint and muscle tension.
• The use of a pregnancy pillow (C- or U-shaped) can provide global support: placed between the knees, it aligns the pelvis, supports the weight of the bump, and offers comfortable support for the arms, preventing the shoulders from closing forward during sleep.

The Importance of Adapted Physical Activity

Maintaining an adequate level of physical activity, in the absence of obstetric contraindications, is one of the most effective methods to prevent musculoskeletal pain. Low-impact activities such as swimming, water aerobics for pregnant women, prenatal yoga, and clinical Pilates help maintain muscle tone, improve flexibility, and promote correct postural awareness. Water, in particular, partially cancels the effect of gravity, offering immediate relief from body weight and allowing fluid and painless movements for the vertebral column.

The Role of Physiotherapy in the Treatment of Neck Pain in Pregnancy

When prevention and ergonomic modifications are not enough to control pain, physiotherapeutic intervention becomes essential. Treating a pregnant woman requires specific skills and an extremely delicate approach, based on the biopsychosocial model. It is imperative that any therapeutic path is undertaken only after consulting your doctor or physical therapist, to ensure maximum safety for the mother and the fetus.

Manual Therapy and Gentle Mobilizations

Manual therapy represents a treatment of choice, as it allows dysfunctions to be treated without the use of drugs. The techniques used must take into account the ligamentous laxity induced by relaxin; therefore, high-velocity, low-amplitude manipulations (so-called “thrusts” or cracking) are generally avoided or used with extreme caution and only by highly specialized personnel. Instead, the following are preferred:

• Low-velocity joint mobilizations: Gentle techniques to restore the correct gliding of the cervical and thoracic facet joints, reducing stiffness without stressing the ligaments.
• Myofascial treatment: Moderate ischemic pressure on active trigger points (for example, in the trapezius, levator scapulae, and splenius capitis muscles) to deactivate foci of referred pain.
• Decontracting therapeutic massage: Performed with adequate pressure, it promotes muscle relaxation, improves local vascularization, and induces a calming effect on the central nervous system, reducing pain perception.
• Muscle energy techniques (MET): These use active and gentle contractions by the patient against resistance offered by the therapist to lengthen retracted muscles and mobilize joints safely.

Instrumental Physical Therapies: What is Allowed and What is Contraindicated

The use of electromedical devices during pregnancy is an extremely delicate topic. Many physical therapies commonly used for neck pain in the general population are contraindicated in pregnant women due to potential teratogenic effects or uterine stimulation (Sabino et al., 2018). Evaluation by your doctor or physical therapist is more mandatory than ever in this area.

Practical Exercises and Tips for Self-Management

Therapeutic exercise is the pillar of long-term rehabilitation. A well-structured exercise program helps counteract postural changes, strengthen weak muscles, and lengthen retracted ones. The exercises described below are for informational purposes only; it is essential that their execution is approved and supervised by your doctor or physical therapist to adapt them to the trimester of pregnancy and individual clinical conditions.

Cervical Mobility and Stretching Exercises

The goal of these exercises is to maintain joint range of motion and reduce muscle tension. They must be performed slowly, without ever evoking acute pain, but only a sensation of mild and pleasant tension.

1. Cervical Retraction (Double chin exercise): In a seated or standing position, looking straight ahead. Slowly draw the head straight back horizontally, as if trying to create a “double chin,” without tilting the head up or down. Hold the position for 3-5 seconds and release. This exercise counteracts forward head posture and strengthens the deep neck flexor muscles. Repeat 10 times.
2. Upper Trapezius Stretch: Seated, with a straight back. Place the right hand under the right thigh to stabilize the shoulder. Gently tilt the left ear towards the left shoulder. To increase the stretch, the left hand can be used to apply very light pressure to the head. Hold for 20-30 seconds while breathing deeply. Repeat 3 times per side.
3. Slow Rotations: Slowly turn the head to the right, trying to look over the shoulder, hold for 2 seconds, then turn to the left. Perform 5-10 fluid movements per side, avoiding jerky movements.

Scapular Strengthening and Stabilization Exercises

To support the neck, it is essential to strengthen the back and shoulder blade muscles, counteracting thoracic kyphosis and anterior shoulder posture.

• Scapular Retraction: In a seated or standing position, with arms by your sides. Squeeze the shoulder blades together towards the center of the spine, opening the chest. Imagine having to squeeze a pencil between your shoulder blades. Hold the contraction for 5 seconds and relax. Repeat 15 times.
• Wall Angels: Lean with your back against a wall (if the volume of the abdomen allows it without arching the lower back too much). Bring your arms into a “goalpost” position against the wall (elbows flexed at 90 degrees). Slowly slide your arms upward while maintaining contact of elbows and wrists with the wall, then return to the starting position. Repeat 10 times.

Relaxation Techniques and Diaphragmatic Breathing

Breathing plays a fundamental role in managing neck pain. As mentioned, stress and pain lead to apical thoracic breathing that overloads the neck muscles. Re-educating diaphragmatic breathing is essential.

In a comfortable position (seated or in lateral decubitus), place one hand on the chest and one on the abdomen. Inhale slowly through the nose, trying to inflate only the abdomen (the hand on the chest must remain still). Exhale slowly through the mouth, letting the abdomen deflate. This technique not only deactivates the accessory muscles of respiration at the cervical level but also stimulates the vagus nerve, inducing a deep state of systemic relaxation and reducing pain perception.

Conclusions

Managing cervical problems during the months of gestation requires a holistic and multidisciplinary approach. The profound hormonal, biomechanical, and postural changes make the vertebral column particularly vulnerable to mechanical stress. Understanding the origin of the pain is the first step to addressing it effectively. Through the adoption of correct ergonomic rules, the execution of targeted therapeutic exercises, and the support of safe and specific manual therapy treatments, it is possible to significantly control pain symptoms. It is of vital importance to remember that every pregnancy is unique and that self-medication or the execution of unvalidated therapies can involve risks. Therefore, constant consultation with the gynecologist and relying on your doctor or physical therapist represent the guarantee for a safe therapeutic path, allowing the future mother to experience this special period with greater serenity and physical well-being.

Differences Between Cervicalgia and Cefalea Tensiva Cervicogenica

While both conditions involve neck discomfort during pregnancy, cervicalgia is primary neck pain caused by muscle tension, postural strain, or ligament stress, whereas cervicogenic tension headache originates from cervical spine dysfunction but manifests as headache. Cervicalgia typically presents with localized neck stiffness and limited range of motion, while cervicogenic headaches radiate toward the head and temples. Diagnosis requires clinical examination and sometimes imaging for cervicalgia, whereas cervicogenic headaches are identified through symptom patterns and cervical provocation tests. Recovery timelines differ significantly, with cervicalgia often improving within weeks with proper posture and physical therapy, while tension headaches may require longer management. Pregnant individuals experiencing either condition should consult healthcare providers for accurate diagnosis and safe treatment options during pregnancy.

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