What science says about forward head posture and neck pain

If you had spent many hours on your phone or computer, you may have heard warnings about forward head posture. Some clinicians and fitness trainers claim on social media that forward head may damage your neck and spine and is the primary cause of migraines. 

Does scientific evidence support this idea? Well, the short answer is the relationship between forward head (sometimes called “text neck”) and neck pain is more complicated and less alarming than many people think. Let’s take a closer look.

What is forward head posture?

Forward head posture is where your head protrudes in front of your shoulders instead of resting on top of them, and your ears are in front of your torso’s midline. It also involves the hyperextension of the upper cervical spine and flexion of the lower cervical spine.

Common symptoms of forward neck may include:

• Tight deep neck and chest muscles
• Headaches
• “Pins and needles” and/or numbness in your hands and arms
• Rounded shoulders and kyphosis

Some evidence suggests that a forward head posture can reduce your lungs’ and breathing muscles’ ability to maximize air intake. Researchers in a 2019 study of 15 healthy, young men reported that when the head sticks forward to its maximum length, movement in the lower abdominal cavity decreases. “The forward head posture causes expansion of the upper thorax and contraction of the lower thorax,” the researchers wrote. 

According to their analysis, the lower chest doesn’t move as much in the front-to-back direction when the subjects with forward head posture breathe. They wrote that one possible reason is that forward head posture can shorten the abdominal muscles. When these muscles shorten, they can limit how much the lower chest can expand because they reduce its front-to-back size. This smaller space means the lower chest can’t move as freely, which also limits how far the diaphragm can move. Since the diaphragm sits at the bottom of the chest, less movement of the lower chest leads to less diaphragm movement.

Forward head posture may increase the risk of excessive wear-and-tear in the upper cervical spine, as well as headaches, bone spur development, and nerve impingement, according to a 2020 study. However, the evidence are based on individual case studies and cannot be extrapolated to the general population.

Research on forward head posture and pain

Some research finds small, average differences in neck and head posture between people with and without neck pain. Many people with forward head posture have no pain, and many with pain have “good” posture.

For example, a 2019 systematic review and meta-analysis of 15 studies found “no statistically significant difference in the [forward head posture] between asymptomatic and neck pain subjects.”

However, the researchers did find that adults with neck pain showed more forward head posture than teenagers and older adults, but this only showed a correlation, not causation.

The researchers are uncertain why there’s such a difference, but they hypothesized that teenagers tend to have higher muscular endurance in the deep neck flexors than adults. Plus, some adults have adopted the forward head posture far longer than teenagers, which may explain why they’re more likely to have neck pain. But that doesn’t explain why older adults showed similar results as teenagers. 

These hypotheses also don’t explain why many teenagers and children suffer from chronic neck pain regardless of what neck curvature they have.

Further research doesn’t support the idea that forward head posture causes neck pain.

• A 2020 Spanish study examined 96 college students from the University of Acalá with 64 students without pain and 32 students with neck pain. The researchers measured neck flexion, extension, and rotation with students in a sitting position. 

  They found that those with forward head posture have higher sensitivity and lesser neck range of motion than those with no pain. But they reported that “forward head posture is not associated with the presence of neck pain, headache, or disability.”Perhaps sticking their head forward is an adaptation to neck pain rather than the posture causing their pain.

• In 2019, a group of Italian researchers found “no significant correlations” between the number of hours spent looking at a smartphone with neck pain and disability among 238 young medical students. About half of the sample reported to have no neck pain. They suggested that “young people can continue to use their cell phones as they prefer.”

• Israeli researchers do not find a significant difference between neck posture and non-specific neck pain among 43 adults. Those with neck pain moved their neck slower and with less range of motion. 
•  A 2018 meta-analysis from Henan, China, reviewed 21 studies—with a total of more than 15,000 subjects— found no significant differences between those with pain and those without pain. However, women had a higher neck lordosis angle than men, and older adults also tend to have such higher angles than younger adults.
• In 2013, a large study in Hirosaki, Japan, also found very little association between the neck curvature and neck pain among 762 men and women in their twenties to eighties. 
• A Swiss study in 2006 found no association between the curve of the cervical spine and neck pain among X-rays of 54 subjects with neck pain and 53 without neck pain. The researchers wrote that there was “no significant differences between the pain and no pain groups for either the total curvature or the segmental curvature at any level.”

• Interestingly, researchers in Quebec, Canada, examined three groups of subjects with acute neck pain, chronic neck pain, and no neck pain. They found that people with huge cervical lordosis have no pain yet chronic neck pain sufferers had the least amount of neck lordosis. Those with acute neck pain are somewhere in between the other groups.
• Similar studies before smartphones also found similar results in Norway (1985) and Finland (1997, 2004). 

With such conflicting messages, this led some researchers to question the prognosis and the relationship between neck posture and pain. They said that there’s a tendency for clinicians to find proper spinal alignment as “appealing,” and thus, they think that’s something they strive for.

“It is surely difficult to find definite answers considering that pain as a biopsychosocial phenomenon is probably too vast a problem to be simply reduced to any kind of measures, no matter how sophisticated and appealing [it] may be,” they wrote.

What really drives neck pain

A 2022 review published in JOSPT stated that neck pain is “multifactorial” with risk factors, such as being female, older, low social support, and a history of neck or lower back pain. Led by Dr. Somayeh Kazeminasab from Tabriz University of Medical Sciences in Tabriz Iran, the researchers also identified several psychological factors that drive neck pain, such as depression, anxiety, low sleep quality, alcoholism, and stress. 

Chronic neck pain “might play some role in changing the central pain processing within the spine, brainstem, or cortical levels,” they wrote.

Behavioral and work-related factors

Kazeminasab at al. wrote that dangerous behaviors, digital habits, and abnormal eating-related behaviors, such as food insecurity, are common in early adulthood, which may contribute to developing chronic neck pain. They also cited that people with neck problems, such as from a whiplash, “complain of neck pain for a shorter period of time when they share their concerns with others and receive social support and understanding.”

Regarding work and neck pain, Kazeminasab et al. reported that low job control, routine work, lack of decision making opportunities, low ability to influence working conditions, low job satisfaction, high job strain, and long-term computer usage increase the likelihood of getting neck pain.

Biological factors

Kazeminasab at al. identified several biological factors that may contribute to neck pain.

Neuromuscular factors

Cervical spondylosis: Progressive age-related degeneration of the cervical spine (discs, joints, bones), sometimes caused by factors like canal narrowing, osteoarthritis, trauma, and disc wear.

Fibromyalgia: Chronic widespread pain with fatigue, sleep issues, cognitive problems, and mood symptoms. Neck pain is the most common complaint.

Cervical radiculopathy: Compression or irritation of cervical nerve roots, often from spondylosis, instability, trauma, or tumors. Main symptoms are neck and shoulder pain.

Whiplash-associated disorders (WADs): Symptoms triggered by sudden acceleration–deceleration forces (e.g., car crashes).

Autoimmune diseases

Rheumatoid arthritis: Chronic inflammation of joints and ligaments, including the cervical spine. More than half of patients show cervical involvement.

Polymyalgia rheumatica: Chronic inflammatory disorder causing stiffness and aches in the neck, shoulders, and hips. Mostly affects people over 50; likely linked to age-related immune activation.

Multiple sclerosis (MS): Inflammatory autoimmune disease affecting the CNS. Neck pain varies with age, sex, disease duration, fatigue, and depression.

Ankylosing spondylitis: Progressive spinal arthritis causing inflammation in spinal joints, including the cervical spine.

Systemic lupus erythematosus (SLE): Systemic autoimmune disease with widespread inflammation. Neck and back pain can result from inflamed muscles; chronic pain and fatigue are common.

Myositis: Rare autoimmune disease causing severe muscle inflammation and progressive weakness. More common in females.

Psoriatic spondylitis: A spinal form of psoriatic arthritis, causing inflammation, pain, and stiffness in the back and neck.

Genetic factors

Kazeminasab et al. reported that twin studies show higher similarity in identical vs. fraternal twins, supporting a genetic role, especially in early adolescence. However, this similarity decreases with age.

They also identified genetic regions associated with neck and shoulder pain:

• Intergenic region on chromosome 17
• FOXP2 gene on chromosome 7
• LINC01572 gene on chromosome 16

However, the researchers wrote that the evidence is limited.

Do forward head posture treatments work?

Exercise

Exercise may reduce neck pain and improve the neck posture, but only at the angle between your C7 and the middle of your ear, according to a 2018 systematic review of seven studies with 627 subjects. 

However, the researcher noted that the study designs and subjects were all different so they couldn’t make blanket conclusions about exercises that would work for everyone. 

For example, a 2020 study of a 4-week exercise program to correct forward head among 30 teenagers in India didn’t find much improvement in changing their neck posture. However, those in the exercise group had better movement and function than the control group.

Kinesio Tape

Taping is a popular way to provide short-term pain relief among athletes. One popular tape is Kinesio Tape, which has been shown to provide some pain relief and improve your body awareness (proprioception). 

However, most research shows that it’s not any better than exercise in pain reduction or changing your posture.

Chiropractic adjustments

Chiropractic and other manual therapy adjustments are often sought for changing their neck posture and pain relief. 

While some research finds pain relief with neck adjustments among those with acute neck pain, there’s not much difference between exercise only and exercise with neck adjustments. 

But keep in mind the risks that are associated with neck adjustments, such as stroke and headaches.

Neck brace

While there are no reviews yet about how effective a neck brace is for forward head or chronic neck pain, research for whiplash injuries finds no benefits of a stiff neck brace for neck pain. 

However, neck braces that allow some neck movement are more effective in pain reduction and mobility. 

What causes forward head posture?

While neck posture is poorly associated with neck pain, some studies indicate other factors that are more likely to cause neck pain rather than structure alone.

A 2016 Australian study, led by Dr. Karen Richards from Curtin University, found that the slump sitting posture among more than 1,100 17-year-olds, are influenced by:

• Body mass index (BMI)
• Exercise frequency
• Sleep quality
• Stress
• Depression

Rather than lumping all the subjects into one group, Richards et al. divided the subjects into four clusters:

1. Cluster 1 (“upright”): Has the least neck flexion, head protraction, and thoracic kyphosis
2. Cluster 2 (“intermediate”): Same as Cluster 1 but with only slightly more thoracic kyphosis
3. Cluster 3 (slumped thorax/forward head): Has the highest amount of thoracic kyphosis and forward head posture
4. Cluster 4 (straight thorax/forward head): Same as Cluster 1 but with forward head posture.

While the researchers hardly found any differences between neck and upper back posture with pain, they found Cluster 3 “higher odds of depressive symptoms.” Cluster 1’s usage of the computer and smartphone was not much different than the other clusters, but it is more physically active which may contribute to a more upright posture.

“The current results do not support the commonly held clinical and societal belief that [neck pain] is related to spinal posture,” Richards et al. wrote. This is consistent with the findings from previous systematic reviews that found a weak relationship between neck pain and posture.

“This suggests that [neck pain] is associated with changes in pain regulatory mechanisms rather than biomechanics,” Richards et al. wrote. “This supports calls to consider and manage [neck pain] from a broader biopsychosocial perspective.”

They question the posture advice that teenagers and adults often get not only from their doctors but also what they see and hear online.

“[Your head] is designed so you can look forward, to the left, to the right, look up—and yes, look down,” wrote Dr. Bronnie Thomposon in her blog, who teaches at the University of Otago in New Zealand on living well with chronic pain. 

She pointed out that many of the biomechanical measurements do not account for living tissues and the adaptive brain and nervous system. 

“If you hold any muscle in one position for long enough it will probably be uncomfortable,” Thompson wrote. “It’s a good thing to feel uncomfortable not because you’re doing any damage to the area, but because it means you’ll move.”

And any changes to what science suggests about posture and pain would take many years and probably even more studies and data to overturn the existing body of knowledge. 

Remember: Before smartphones, people already have a forward head from reading, drawing, and doing crafts.