Cervical Vertigo and Cervicogenic Dizziness – Neck pain and dizziness

Ross Hauser, MD

Cervical Vertigo and Cervicogenic Dizziness are often used as interchangeable terms to describe dizziness that has its origin in problems of the neck.

For many people with neck pain and symptoms of vertigo and dizziness, common sense and their own awareness of their daily quality of life suggest to them that the many symptoms they have must be interconnected. There can be no other explanation. Yet for many of these people, their symptoms are divided up and distributed among specialists to be given individual focus. Digestive problems and nutritional disorders are sent to the gastroenterologist, cardiovascular-like problems are sent to the heart specialist, and balance and dizziness issues are sent to the ENT and then possibly a neurologist. Rarely do these specialists talk to each other, rarely is there a “master plan” or grand unifying attempt to get these patients into a treatment program that addresses them as a whole.

It is for this reason that we will often get an email asking “Can a pinched nerve in the neck cause vertigo?” This email may be coming from someone who has battled many symptoms for many years and it is through their own research or an appointment with an enlightened physical therapist, chiropractor, or doctor that the idea that a pinched nerve in their neck may be their “ground zero” for the cause of many of their symptoms. This may describe you, you may be on this article because you are searching for support material to validate or dismiss this idea of a pinched nerve in the neck causing among other things, cervical vertigo, dizziness, and balance issues.

Here are some examples of the symptomology people who reach out to our clinic suffer from.

When I turn my head I get dizzy.

  • I have dizziness, ear pain, and fullness. It happens when I look down or move my head forward to get a closer look at something. On other occasions, when I turn my head, I get a sudden dizzy spell. Sometimes after the dizziness goes away I get a long-lasting headache.

After the car accident.

There was no “event,” that triggered this.

  • I have been dealing with my dizziness and other problems for a few years now. There was no “event,” that triggered this, I have always been active in sports and have taken my fair share of knocks to the head. I had been to the chiropractor a couple of times to get my neck and back cracked. I found these treatments helped me with the chronic nagging pain I often get from a job that requires me to sit all day.

No one wants to believe me because an MRI of my head doesn’t show anything.

  • I have had problems with dizziness and balance for almost ten years now. No one wants to believe me because an MRI of my head doesn’t show anything. When I complained about neck pain, another MRI “did not show enough,” to justify surgery. I do have migraines and no hearing problems, but problems with noise sensitivity. Since I have an “ear problem,” now I am being sent for vestibular rehabilitation to focus on my ear as being the cause of the dizziness. I told my doctor that is not what I think it is. They think I am crazy.

I am arguing with my doctor that he is recommending me to get surgery that I do not need

  • I have been going from one specialist to the next. It started with dizziness and then it became dizziness with tinnitus. Then it became dizziness, tinnitus, worse hearing, and now vision problems. The thing is in all the MRIs I have been getting, my neck one shows herniated discs from C3-C7 and some problems at C1-C2. My doctor is telling me that he thinks all my problems will go away with a cervical fusion. I think it will make my problems worse.

Now it is more than just dizziness – new symptoms

  • One day I was at home getting ready to leave for work when suddenly everything started to spin. I had simply bent over to grab my bag. I fell over. I was able to call for help and I was taken to the emergency room by ambulance. Scans of my head revealed no abnormalities or problems. The attending physician thought this to be a temporary problem. I was given a prescription for Meclizine and as soon as my dizziness cleared. I was sent home.

Over the next few months and years, I had occasional dizziness, sometimes severe enough to send me for emergency care and an emergency room x-ray of my head and neck.  All the doctors could tell me was that they suspected some type of post-traumatic concussion syndrome or whiplash-related disorders. At the last emergency room visit, it was recommended to me that I get “more aggressive,” with seeking out what was wrong with me.

I now began the more aggressive course of action that started with physical therapy. At PT, my therapist recommended that I go back to the doctor and get a referral for an ENT specialist, a neurologist, and a cardiovascular specialist. Let’s “rule out what is not wrong with you.”

What are we going to discuss in this article?

  • The diagnosis and treatment of cervical vertigo and chronic dizziness are associated with neck movement. Or more commonly for some, a diagnosis of Benign Paroxysmal Positional Vertigo and worsening of its symptoms.
  • We present research on when neck pain causes dizziness and possible conservative treatment options.

Article Outline:

Part 1: Understanding the diagnosis of cervical dizziness

  • The prevalence of cervical dizziness is still not recognized by the entire medical community.
  • Doctors too are looking for validation of the relationship between cervical pathology and dizziness.
  • Finally, doctors began to study the cervical spine as a cause of dizziness.
  • “A non-resolved dysfunction of the upper cervical spine was a common cause of long-lasting dizziness in our population.”
  • “Functional examination of motion segments of the upper cervical spine is important in diagnosing and treating vertigo.”
  • You have likely been asked the key questions numerous times: How often do you get dizzy? Do you get dizzy when you look up? Look down? All around?
  • The controversy surrounding a diagnosis of cervical vertigo and why no one has been able to help you.
  • Proprioceptive cervical vertigo. Is dizziness the problem of a pinched nerve in the neck?
  • Proprioceptive cervicogenic dizziness – “cervicogenic” it’s coming from the neck.
  • Mismatched information integration manifests as a variety of symptoms, including dizziness, pain, lightheadedness, and headache.

Part 2: Diagnostic Testing

  • Finding the source of dizziness is a matter of exclusion and a process of elimination – The Tests.
  • Digital motion X-ray showing C1-C2

Part 3 Conservative Care Treatment Options

  • Nerve blocks to assist with dizziness and neck pain.
  • Chiropractic manipulation and physical therapy: The hunt for muscle pain, muscle spasms, and weakened neck muscles as the cause of dizziness.
    • A 49-year-old female with acute onset of vertigo and imbalance following self-manipulation of the cervical spine.
    • Self-exercise could improve a patient’s dizziness.
  • Looking at a muscular cause for this is confusing to researchers because there do not appear to be consistent answers. What did the physical therapists find?
  • Why physical therapy may not help neck pain and secondarily, vertigo. Tendonitis.
  • Thicker muscle is because muscles are trying to do a job it is not intended to do, the job of the cervical ligaments and keeping the vertebrae in place.
  • So what do we have here and what does it mean to you? Something is pressing on your nerves and arteries causing a dizzy situation.

Part 4 Surgical Recommendations for Cervicogenic Vertigo

  • Various surgical options.
  • Coblation nucleoplasty.
  • Anterior cervical discectomy and fusion (ACDF).

Part 5: Cervical instability and vertigo – non-surgical options that focus on the cervical ligaments

  • Treating cervical ligaments – published research from Caring Medical.
  • Disabling dizziness from neck instability was treated successfully with Prolotherapy.
  • Non-surgical treatment – Cervical Spine Stability and Restoring Lordosis -Making a case for regeneration and repair of the spinal ligaments.
  • Caring Cervical Realignment Therapy (CCRT)
  • Treatments for cervical spine realignment – restoring the curve without surgery.

Part 1: Understanding the diagnosis of cervical dizziness

I start this article with the below quote from doctors who see as we have seen, the damage that the poor posture of the technological age has caused on the cervical spine and the length of debate surrounding what is causing the symptomatic problems many people suffer from. Further, this debate extends into controversies of how to treat these people and if what they are suffering from (cervical vertigo) actually exists as a diagnosis. Neck pain and dizzy spells are not typically isolated problems. The person who suffers from these disorders will usually, almost always suffer from many problems, and they will all be related to each other. Let’s get to the research.

The prevalence of cervical dizziness is still not recognized by the entire medical community

A December 2022 paper writes: (1) “The prevalence of cervical dizziness, still not recognized by the entire medical community, not only does not become less frequent but even increases today. This phenomenon is facilitated by the widespread computerization of our lives and, in particular, the strain on the neck when working with portable electronic equipment. Even though criteria that reliably confirm the association of dizziness with cervical pathology has not yet been defined, experimental and clinical evidence of such an association continues to accumulate.”

What the research suggests is that the evidence of dizziness and cervical spine problems is there. No one has yet to publish an accepted paper that puts it all together.

Doctors too are looking for validation of the relationship between cervical pathology and dizziness.

Above we read about people and their stories. Their stories contain fear and confusion and sometimes conflicting ideas with their doctors as to what is wrong with them. Doctors too are looking for answers, including the relationship between neck pain and dizziness.

Let’s look at an April 2020 study from the Department of Otorhinolaryngology and Head and Neck Surgery, Haukeland University Hospital, in Norway. The paper was published in the journal Physiotherapy Research International. (2)

In this paper, the researchers wanted to know if dizziness severity and degree differed between patients who only suffered from dizziness and patients who suffered from dizziness and neck pain. In other words, how did neck pain contribute to dizziness as compared to people with dizziness without neck pain?

Here are the summary learning points:

  • The patients in this study with dizziness and neck pain were recruited from an ear-nose-throat department and a spine clinic.
  • They were divided into three groups:
    • patients with dizziness only (100 patients),
    • patients with dizziness as their primary complaint and additional neck pain (138 patients) and finally,
    • patients with neck pain as their primary complaint accompanied by additional dizziness (55 patients).
  • The patients filled in questionnaires regarding their symptom quality, time course, triggers of dizziness, and the Vertigo Symptom Scale Short Form. The physical examination included Cervical Range of Motion, American College of Rheumatology (ACR) Tender Points, Cervical Pressure Pain Thresholds, and Global Physiotherapy Examination 52-Flexibility (this test, considered controversial by some, measures Posture, Respiration, Movement, Muscle function, and stretchy skin characteristics.)

Results:

  • Both neck pain groups were more likely to have a gradual onset of dizziness symptoms, more light-headedness, visual disturbances, autonomic/anxiety symptoms, decreased cervical range of motion, decreased neck and shoulder flexibility, and increased number of ACR tender points compared with patients with dizziness alone.
  • The group that had dizziness as their primary complaint and also reported neck pain had the highest symptom severity and tended to report rocking vertigo and increased neck tenderness.
  • The group with neck pain as their primary complaint was more likely to report headaches.

Conclusion: Neck pain is associated with certain dizziness characteristics, increased severity of dizziness, and increased physical impairment when compared with dizzy patients without neck pain.

Finally, doctors began to study the cervical spine as a cause of dizziness.

When we started our regenerative medicine practice back in 1993, one of the phenomena we studied in neck pain patients was, why did they have dizziness. So for us, treating the neck for problems of dizziness, balance, and healing problems is not a new phenomenon. But at the time was certainly something debated. Does neck instability cause dizziness?

“A non-resolved dysfunction of the upper cervical spine was a common cause of long-lasting dizziness in our population.”

In 1998, just over 26 years ago, the connection to cervical neck pain and dizziness was not only not understood, but it was also rarely studied. Then doctors started publishing papers that neck pain and dizziness were related.

Listen to what German researchers wrote back then in the European Spine Journal. (3) This research is important today as it is often used as a starting point of the cervical neck/dizziness connection debate: In this research, treating cervical neck instability made vertigo go away.

The research paper begins:

To our knowledge, quantitative studies on the significance of disorders of the upper cervical spine as a cause of vertigo or impaired hearing do not exist.”

To test their hypothesis that upper cervical disorders caused dizziness, the German doctors examined the cervical spines of 50 patients who presented with symptoms of dizziness. Prior to the orthopaedic examination, causes of vertigo relating to the field of ENT and neurology had been ruled out.

  • The patients were treated with physical therapy and were available for 3 months of follow-up.
  • Thirty-one patients,  group A, were diagnosed with dysfunctions of the upper cervical spine.
    • In group A, dysfunctions were found:
      • at level C1 in 14 cases,
      • at level C2 in 6 cases, and
      • at level C3 in 4 cases.
      • In seven cases more than one upper cervical spine motion segment was affected. Dysfunctions were treated and resolved with mobilizing and manipulative techniques of manual medicine.
  • Nineteen patients, in group B, did not show signs of dysfunction.
  • Regardless of cervical spine findings seen at the initial visit, group A and B patients received intensive outpatient physical therapy.
  • At the final 3-month follow-up,
    • 24 patients of group A (77.4%) reported an improvement in their chief symptom and 5 patients were completely free of vertigo.
    • Improvement of vertigo was recorded in 5 group B patients (26.3%); however, nobody in group B was free of symptoms.

The researchers concluded that “functional examination of motion segments of the upper cervical spine is important in diagnosing and treating vertigo because a non-resolved dysfunction of the upper cervical spine was a common cause of long-lasting dizziness in our population.”

“Functional examination of motion segments of the upper cervical spine is important in diagnosing and treating vertigo.”

Why do we find this one sentence so remarkable?  Because this one line may be the answer for many of you reading this article. Let’s explain.

The researchers suggest that you must examine the motion segments of the upper neck because it is the unresolved (non-treated) vertebral segments that are causing the problems. In our 31+ years of service in treating cervical neck disorders, we have found that many patients who come through our doors do not have an accurate diagnosis or assessment of their situation.

You have likely been asked the key questions numerous times: How often do you get dizzy? Do you get dizzy when you look up? Look down? All around?

You have likely been asked the key questions numerous times: 

  • How often does the dizziness occur?
  • Is there anything that triggers the dizziness, such as sudden head movements?
  • How long does the dizziness last?
  • Have you ever fallen because of dizziness?
  • Do you get nausea, do you vomit?
  • Do you get dizzy when you look up? Look down? All around?
  • Is the room spinning?

You may also be tired of answering these same questions because no one has seemed to help you.

Your doctor may have offered you a diagnosis of benign paroxysmal positional vertigo or BPPV with a somewhat reassuring tone that your dizziness, loss of balance, sometimes nausea, sometimes vomiting is something that can be managed, and may go away on itself, and this will be more of a nuisance than anything. That is why it is called “Benign.”

For some people, it may end at just that, a nuisance. These are usually not the people that come into our offices. We see the people whose symptoms have progressed to include double vision or sight problems and other challenges. These are related below.

The controversy surrounding a diagnosis of cervical vertigo and why no one has been able to help you

Sometimes a patient will tell us that they went to a specialist and were told that there is no such thing as cervical vertigo. Pursuing this diagnosis was not helpful. Above we examined one study that tried to make a connection between neck pain and dizziness. Let’s look at another. The title of this research study is: “Cervical Vertigo–Reality or Fiction?” This June 2019 study (4) offered these statements:

  • “The existence of cervical vertigo is still a question under debate. The basic hypothesis of the disease is that the abnormalities of the neck cause dizziness.”
  • “The most common symptoms of cervical vertigo are cervical pain or discomfort, imbalance or dizziness, and limitation of cervical movement”
  • “When diagnosing cervical vertigo, we always face the following difficulties: there is no diagnostic method specific to the disease, pathognomic (obvious symptoms that point to cervical vertigo) clinical elements are unavailable, and no clear therapeutic recommendation exists. The diagnosis of the disease requires the exclusion of alternatives, but the possibility of the existence of psychogenic (a sense of hypochondria) vertigo causes further difficulties for clinicians. Regarding the treatment, the combination of manual therapies and vestibular rehabilitation seems to be the most effective. “

It should be pointed out that despite the confusion and the controversy, manual therapies, treatments that address the cervical spine, and physical therapy seem to be the best answers.

Cervical Vertigo–Reality or Fiction?” Two studies 23 years apart, ask the same exact question.

In 1996, 23 years earlier, a research study (5) also had the same exact title: “Cervical Vertigo–Reality or Fiction?” The answer to the question, in 23 years, had still not been sufficiently answered.

In this 1996 study, Professor Thomas Brandt of the Department of Neurology at the University of Munich offered this assessment:

“Neck afferents (nerves) not only assist the coordination of eye, head, and body, but they also affect spatial orientation and control of posture. This implies that stimulation of, or lesions (damage) in, these structures can produce cervical vertigo. . . Neurological, vestibular, and psychosomatic disorders must first be excluded before the dizziness and unsteadiness in cervical pain syndromes can be attributed to a cervical origin. To date, however, the syndrome remains only a theoretical possibility awaiting a reliable clinical test to demonstrate its independent existence.”

Just like your medical journey, the research journey of doctors trying to understand the cause of your dizziness and the origins of cervical vertigo is also a long one.

Please refer to my companion article:

So why is the connection between cervical neck dysfunction and dizziness still controversial?

In this research from 2000, we can demonstrate that twenty-four years later, the problem of cervical vertigo and cervicogenic dizziness still present problems for health providers in identifying and treating these problems and as you know FIRST HAND, problems that cannot be identified in patients ARE OFTEN DISMISSED.

Here is the 2000 research (6from the Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, appearing in the Journal of Orthopaedic & Sports Physical Therapy:

  • The diagnosis of cervicogenic dizziness can be made if the patients suffer from dizziness and dysequilibrium that appears to come from neck pain caused by cervical disc disease and degenerative arthritis.
  • The treatment of an individual presenting with cervical spine dysfunction and associated dizziness complaints can be a challenging experience for orthopedic and vestibular (inner ear and brain) rehabilitation specialists.
    • Note: In addition to dizziness, patients with vestibular disorders can also experience vision problems and problems related to disequilibrium and dizziness such as nausea. This may lead to a diagnosis of an inner ear disorder or tinnitus.

Proprioceptive cervical vertigo. Is dizziness the problem of a pinched nerve in the neck?

Cervical proprioception (a disruption in nerve signaling in the body’s unconscious or involuntary movements – pressure on the nerves) and neck movement limitations

A 2009 study appeared in the Annals of Physical and Rehabilitation Medicine. (7) Here medical university researchers in Tunisia wanted to examine balance disorders in chronic neck pain patients suffering from vertigo and balance instability.

Ninety-two patients having suffered from chronic neck pain for at least 3 months were enrolled in the present study. Patients with a history of neck trauma or ear, nose, and throat, ophthalmological or neurological abnormalities were excluded so as to be able to focus on cervical instability as the cause.

The patients were divided into three groups:

  • a group of 32 patients with neck pain and vertigo (Group 1)
  • a group of 30 patients with chronic neck pain but no vertigo (Group 2)
  • and a group of 30 healthy controls.

Findings in the groups

  • Osteoarthritis was found in 75% of the group of 32 patients with neck pain and vertigo (Group 1).
  • Osteoarthritis was found in 70% of the subjects with chronic neck pain but no vertigo (Group 2).
  • Neck-related headaches were more frequent in patients with neck pain and vertigo (65.5% versus 40%)
  • Restricted neck movement was more frequent in patients with neck pain and vertigo.
  • Balance abnormalities were found more frequently in patients with neck pain and vertigo.

The doctors also noted that the study evidenced abnormal static and dynamic balance parameters in chronic neck pain patients with vertigo. These disorders can be explained by impaired cervical proprioception (a disruption in nerve signaling in the body’s unconscious or involuntary movements – pressure on the nerves) and neck movement limitations. Headaches were also more frequent in these patients.

  • So here we have one of many studies that are now connecting the problems of dizziness, imbalance, and headache to problems of cervical neck instability as attested to by pinched nerves and restricted range of motion in the neck.
  • In other words: The neck is trying to restrict its own movement in much the same way a cervical collar works to prevent pain and symptoms of unstable vertebrae.

Proprioceptive cervicogenic dizziness – “cervicogenic” it’s coming from the neck

A March 2023 paper from researchers at the University of Montreal, published in the Journal of  Clinical Medicine (8) sought to further classify cervicogenic dizziness patients and explain the Proprioceptive cervicogenic dizziness subgroup of patients. These patients have some type of misfiring when it comes to messages from the nervous system to the brain about the body’s position in movement and space. This dysfunction would lead to disorientation and dizziness. Here is what they wrote:

“Proprioceptive cervicogenic dizziness (PCGD) is the most prevalent subcategory of cervicogenic dizziness. There is considerable confusion regarding this clinical syndrome’s differential diagnosis, evaluation, and treatment strategy.” To address the confusion, the researchers of this study sought to classify and categorize diagnoses, symptoms, and treatments as a guide to assist clinicians in helping their patients. They did this by evaluating and assessing data from 156 previously published studies.

Based on the potential origins of the clinical syndrome, the analysis identified four main subpopulations of Proprioceptive cervicogenic dizziness:

  • Chronic cervicalgia (chronic neck pain),
  • Traumatic (injury/accident),
  • Degenerative cervical disease, and
  • Occupational.

The authors noted that about 44% of the studies’ articles acknowledge more than one subpopulation (multiple conditions). Particularly in the chronic cervicalgia analysis.

The three most commonly occurring differential diagnosis categories are:

  • Central causes (problems of the arteries and veins, medication use, etc.)
  • Benign paroxysmal positional vertigo and
  • Otologic pathologies.

The four most cited measures of change (worsening of symptoms) were the:

  • Dizziness handicap inventory,
  • Visual analog scale for neck pain,
  • Cervical range of motion, and
  • Posturography (swaying).

Across subpopulations, exercise therapy and manual therapy are the most commonly encountered interventions in the literature.

In a March 2022 paper in The International Tinnitus Journal (9) doctors at the Department of Otolaryngology-Head and Neck Surgery, University of São Paulo offered an evaluation of neck pain with proprioceptive (with movement) cervicogenic dizziness and how it impacts patients with tinnitus.

Learning points:

  •  After the exclusion of peripheral vestibular disorders, twenty patients with proprioceptive cervical dizziness were selected.
  • A Visual Analogue Scale (VAS) was used to score pain and vertigo.
  • The active neck Range of Motion (ROM) and the muscle strength of the neck region were examined.
    • A positive correlation between neck pain and vertigo VAS pain scores was found.
    • The ROM of the cervical spine was limited and vertebral joint movement was restricted, especially at C3 and C5. No loss of muscle strength was noticed.

The researchers here noted that “Proprioceptive cervical dizziness is usually an exclusion diagnosis among episodic chronic vertigos. . . It is directly related to the neck ache severity and worsens with neck movements.”

Mismatched information integration manifests as a variety of symptoms, including dizziness, pain, lightheadedness, and headache.

A December 2022 study in the journal Medicina (10) suggests how dizziness develops as a result of forward head posture. Incorrect posture alignment might cause Cervicogenic Dizziness by the following process: Forward head posture causes a change in the alignment and an excessive load on the upper cervical spine. These changes cause structural and functional changes in the surrounding muscles, especially the suboccipital muscles. In addition, (symptoms) may persist because of the instability of the ligaments and facet joints. These alterations transmit abnormal proprioceptive inputs (incorrect data of your body in motion) to the central nervous system, resulting in inconsistencies with vestibular and visual inputs (dizziness). Mismatched information integration manifests as a variety of symptoms, including dizziness, pain, lightheadedness, and headache.

Part 2: Diagnostic Testing

 

 

Finding the source of dizziness is a matter of exclusion and a process of elimination – The Tests

In September 2017, doctors at Duke University published research in the Archives of Physiotherapy. (11) Here is the introductory paragraph:

“Cervicogenic dizziness is a clinical syndrome characterized by the presence of dizziness and associated neck pain. There are no definitive clinical or laboratory tests for Cervicogenic dizziness and therefore Cervicogenic dizziness is a diagnosis of exclusion.

It can be difficult for healthcare professionals to differentiate Cervicogenic dizziness from other vestibular, medical, and vascular disorders that cause dizziness, requiring a high level of skill and a thorough understanding of the proper tests and measures to accurately rule in or rule out competing diagnoses.

Consequently, the purpose of this paper is to provide a systematic diagnostic approach to enable healthcare providers to accurately diagnose Cervicogenic dizziness. . .  and provide steps to exclude diagnoses that can present with symptoms similar to those seen in Cervicogenic dizziness, including central and peripheral vestibular disorders, vestibular migraine, labyrinthine concussion, cervical arterial dysfunction, and whiplash-associated disorder.”

Here are some of the tests they reviewed for patients’ cervical vertigo and cervicogenic dizziness and the brief reasoning behind them:

The Duke researchers were very comprehensive. Here are some of the tests they reviewed for patients with chronic conditions and the brief reasoning behind them:

  • Alar Ligament Test – Manual examination –  to assess the integrity of the alar ligaments and upper cervical stability
  • Sharp Purser Test – Manual examination – to assess the integrity of the transverse ligament/upper cervical spine instability
  • Cervical Facet Joint Dysfunction is tested by Manual Spinal Examination. Providers here are looking for pain generators in the facet joints.
  • Cervical Facet Joint Mediated Pain – Palpation for Segmental Tenderness. Providers here are looking into spasms.
  • Cervical Arterial Dysfunction (CAD) – CAD testing involves neck rotation and extension with a stationary body, causing decreased blood flow in the vertebrobasilar arteries with rotation alone and internal carotid arteries with combined extension and rotation. CAD testing requires cervical extension and rotation passive range of motion that is within normal limits.
  • Head Thrust Test – a manual examination in which the movement of the patient’s eyes is monitored as they are fixed on the health care provider giving the test.
  • Cervical Neck Torsion Test – a manual examination in which the movement of the patient’s eyes is monitored as they follow a mobile object side to side
  • Cervical Relocation Test – this is a test that is often reviewed in the literature and is the subject matter for a later independent article on our site. Simply this test gauges the patient’s ability to return their head to a “neutral” position after movement.
  • Dix-Hallpike to test for benign paroxysmal positional vertigo episodes of dizziness and a sensation of spinning with certain head movements. benign paroxysmal positional vertigo.

Let’s point out again that the Duke team suggests that diagnosis is difficult and is sort of like peeling an onion, there are many layers that need to be peeled away, Cervicogenic dizziness is a diagnosis of exclusion.

In research published by Caring Medical:  Chronic Neck Pain: Making the Connection Between Capsular Ligament Laxity and Cervical Instability led by Danielle Steilen-Matias.(12) Our team also suggested that the diagnosis of chronic neck pain due to cervical instability is particularly challenging. In most cases, diagnostic tools for detecting cervical instability have been inconsistent and lack specificity, and are therefore inadequate. A better understanding of the pathogenesis of cervical instability may better enable practitioners to recognize and treat the condition more effectively. For instance, when cervical instability is related to injury of soft tissue (eg, ligaments) alone and not fracture, the treatment modality should be one that stimulates the involved soft tissue to regenerate and repair itself.

Digital motion X-ray showing C1-C2

Often a patient will tell us that they had a myriad of lab tests looking for the source of their frequent, occasional, or most of the time dizziness. At the end of these tests, the patient started looking for other doctors to help them. When they are sitting in our clinic they will often tell us, “After all the tests, I was still dizzy, and worse, there seemed to be no plan to help me.”

This is another of our videos, it gives a clearer view of C1-C2 instability in a patient.

For more details please see my companion article: Reviews of Diagnostic Imaging Technology for Cervical Spine Instability Ross Hauser, MD.

Here are some brief explanatory notes. The video is only 1 minute in length.

  • Digital Motion X-ray is a great tool to show instability at the C1-C2 Facet Joints
  • The amount of misalignment or “overhang” between the C1-C2 demonstrates the degree of instability in the upper cervical spine. How much space there is between the C1 and C2 on certain neck movements?
  • This is treated with Prolotherapy injections (explained below) to the posterior ligaments that can cause instability.
  • At 0:40 of this video, a repeat DMX is shown to demonstrate the correction of this problem.

Part 3 Conservative Care Treatment Options


There are many treatment options for the management of chronic neck pain and cervical vertigo. That you are reading this article is an indication that you may have tried many of these treatments with limited or no results.

These treatments may have included:

  • Cortisone injection.
    • A cortisone injection is typically given in patient complaints of neck pain when inflammation is suspected. It is usually not offered as a treatment directly for cervical dizziness. There is very little research to support cortisone injections in vertigo patients.
  • Nerve blocks to assist with dizziness and neck pain.
    • A May 2018 study from the Department of Neurosurgery, University of Ulm, Germany was published in the journal Pain Physician. (13). Here we should point out that this study was found to be favorable to nerve blocks as a short-term help.
    • One hundred seventy-eight patients were included in this study.
    • One-hundred-eleven patients (62.4%) experienced a significant improvement in vertigo.
    • In 47 patients (26.4%), no information about the vertigo was available at follow-up; these patients were assumed to have no improvement (worst-case scenario). Altogether 67 patients (37.6%) had a negative result.
    • The median relief of vertigo was 2 months.
    • Also note: Nine patients with a whiplash injury in their medical history were also tested. They experienced a lower success rate.

The bottom line is that two-thirds of patients experienced dizziness relief for two months with a nerve block.

Chiropractic manipulation and physical therapy: The hunt for muscle pain, muscle spasms, and weakened neck muscles as the cause of dizziness

  • Chiropractic manipulation and physical therapy
    • For the purpose of this article, we will address both of these treatment modalities as in essence they both seek the same goal. Treating cervical vertigo by putting the cervical spine back into proper anatomical alignment and both may use intermittent traction and/or cervical collars.
    • We should point out here that the goal of our treatments with regenerative medicine injections of dextrose and possibly blood platelets taken from the patient is the same. Putting the cervical spine back where it belongs. We may use intermittent traction and/or cervical collars. However, our treatments differ significantly as we seek more of a curative effect in a short window of treatments and not prolonged care.
    • In chiropractic manipulation and physical therapy, there is an expectation that chiropractic will manipulate the cervical spine back into place and that physical therapy will strengthen the muscles of the cervical neck region to provide support.
    • These treatments typically do not provide a long-term answer as we will see below because they must rely on strong cervical ligaments and strong cervical tendons. If you are reading this article we would have to guess that your cervical ligaments and cervical tendons are weak and strength compromised.

A 49-year-old female with acute onset of vertigo and imbalance following self-manipulation of the cervical spine.

In April 2023, clinicians at the Chiropractic and Physiotherapy Center, New York Medical Group, in Hong Kong reported in the medical journal Cureus (14) on a  case of a 49-year-old female with acute onset of vertigo and imbalance following self-manipulation of the cervical spine.

Examination revealed a restricted cervical range of motion, muscle hypertonicity (stiffness, tightness, spasm), and positive neurological signs (weakness, pain). The clinicians reviewed x-rays which showed that this woman had significant loss of normal cervical lordosis.

The patient was diagnosed with cervicogenic dizziness and prescribed chiropractic treatments that included spinal manipulation, soft tissue release, and rehabilitative exercises. After four weeks of care, her symptoms had improved. At the six-month follow-up, the patient remained asymptomatic with a full cervical range of motion. This case highlights the risks associated with neck manipulation and in this case the effectiveness of chiropractic treatment for cervicogenic dizziness.

Self-exercise could improve a patient’s dizziness

According to researchers writing in February 2023 in the journal Frontiers in Neurology (15), “Recent evidence suggested that self-exercise could improve a patient’s (dizziness) symptoms.” To add to this research, clinicians evaluated the effectiveness of self-exercise as an add-on therapy in patients with non-traumatic cervicogenic dizziness.

  • In this study, the self-exercise group was instructed to perform muscle, mobilization, and oculomotor training at home while there was no specific training given to a control group. The neck pain, dizziness symptoms, and their impact on daily life were evaluated by standard pain and disability scoring.
  • However, there was no statistical difference in the pain scores, the range of motion tests, and posture tests.

Conclusion: “Self-exercise is effective in reducing dizziness symptoms and its impact on daily life in patients with non-traumatic cervicogenic dizziness. ” But in this group of patients did not help pain, range of motion or improve posture.

Looking at a muscular cause for this is confusing to researchers because there do not appear to be consistent answers. What did the physical therapists find?

Like yourself, many people with neck problems and systems of dizziness, after extensive testing, are often sent for exercise or physical therapy to strengthen the neck. For some, there must be a muscle component whether it is atrophy or thickening/swelling.

In July 2020 in the Journal of Physical Therapy Science (16), a group of physical therapists looked at the muscles of their patients who suffered from cervical vertigo. They compared these patients’ muscles with the cervical spine muscles of people who did not have cervical issues or cervical vertigo. What were they looking for and what did they find? Let’s let them answer.

“Cervical vertigo as a common complaint is associated with some musculoskeletal disorders. However, to date, ultrasonographical parameters of cervical muscles in patients with cervical vertigo have not been investigated. (Guidelines to help other health care professionals zero in on the muscles as a possible cause of the patient’s dizziness.) (The researcher’s study) was conducted to investigate the size of cervical muscles in patients with cervical vertigo compared to healthy controls.”

Thicknesses of cervical flexor (If you have been going to physical therapy, these names should be familiar to you: the longus colli, longus capitus, rectus capitus, and longus cervicus muscles) and extensor muscles (the deep muscles, the semispinalis cervicis, and multifidus) were evaluated through ultrasonography and results were compared between the patients and healthy controls.

Results showed that the thickness of the longus Colli muscle (the muscle that helps you look down) was significantly different between the patients and healthy controls. According to the findings of the study, the size of the longus colli muscle is likely to be associated with the etiology of cervical vertigo.”

What does this mean?

The researchers noted: “As the cervical instability may cause abnormal afferent signals (messages between the brain and spinal cord) to the central nervous system and consequently vertigo feeling, the higher thickness of Longus Colli may be a compensatory mechanism in the patients with cervical vertigo.”

Why physical therapy may not help neck pain and secondarily, vertigo. Tendonitis

An October 2022 paper (17) in The Journal of Manual & Manipulative Therapy suggested: “There is moderate quality of evidence that manual therapy reduces cervicogenic dizziness, cervical spine, and balance symptoms. When manual therapy is combined with exercise therapy, the positive effect on cervicogenic dizziness, cervical spine, and balance symptoms is even stronger. However, the quality of the evidence here is very low.

For physical therapy and exercise to be effective in building muscle strength, the muscles must have sufficient resistance to challenge the muscles. The muscle attaches to the bone at the tendon interface. A November 2018 paper in the journal Review Medicine (18) suggested that vertigo was caused by longus colli tendonitis.

Here are the learning points and presented case history of this paper:

  • Tendinitis of the longus colli muscle leads to acute posterior (back of) neck pain, neck stiffness, dysphagia (swallowing difficulties), or odynophagia (painful swallowing).
  • In this paper, the doctors presented a patient exhibiting an infrequent symptom, vertigo. This is the first description of the occurrence of vertigo symptoms caused by longus colli tendinitis.

The patient case:

  • A 38-year-old man was diagnosed with vertigo, presenting with a one-month history of dizziness, palpitations, and numbness in the hands.
  • Diagnosis: Longus colli tendinitis. The diagnosis was established using magnetic resonance imaging fat-suppression sequences.
  • Treatment with corticosteroid injections and acupotomy (a form of acupuncture that uses needles and a surgical scalpel).

Outcomes: The symptoms were relieved immediately after the treatment and complete resolution of the symptoms was observed after 1 week.

Lessons: “Longus colli tendinitis with vertigo is an under-reported condition in the literature and physicians should be aware of its existence. A lack of familiarity with the anatomy of the prevertebral space and its variable radiographic appearance makes the diagnosis of longus colli tendinitis clinically difficult. Misdiagnosis of this condition may lead to unnecessary interventions in vertigo.”

In other words, the muscle is thicker because it is trying to do a job it is not intended to do, the job of the cervical ligaments and keeping the vertebrae in place.

In this image, we see a depiction of a muscle spasm in the back of the neck. Why the muscle spasms, or why it gets thicker is a response to cervical spine ligament injury. The muscle is trying to hold things together to prevent the nerve or cervical arteries from being impinged.

In this image we see a depiction of muscle spasm in the back of the neck. Why the muscle spasms, or why it gets thicker is a response to cervical spine ligament injury. The muscle is trying to hold things together to prevent the nerve or cervical arteries from being impinged.

These researchers did cite another study that you may find of interest because it is something we see in many patients. The inability of the head to return to a normal posture position following certain movements because the vertebrae are not where they should be. They are not lined up correctly. This would lead to muscle thickening. This study comes from the Journal of Rehabilitation Medicine. (19) It deals with whiplash victims and dizziness.

“Dizziness and/or unsteadiness are common symptoms of chronic whiplash-associated disorders. This study aimed to report the characteristics of these symptoms and determine whether there was any relationship to cervical joint position error. Joint position error, the accuracy to return to the natural head posture following extension and rotation, was measured in 102 subjects with persistent whiplash-associated disorder and 44 control subjects. . . The results (of this study) indicated that subjects with whiplash-associated disorders had significantly greater joint position errors than control subjects.”

The researchers noted:

“Within the whiplash group, those with dizziness had greater joint position errors than those without dizziness following (head) rotation (to the right or left) and a higher neck pain index (score). . . Cervical mechanoreceptor dysfunction (simply the sensors in the neck that transmit information based on touch, pressure, stretching, and motion) is a likely cause of dizziness in whiplash-associated disorder.”

So what do we have here and what does it mean to you? Something is pressing on your nerves and arteries causing a dizzy situation.

Possible injuries such as whiplash or degenerative disease or diseases possibly hEDS (Ehlers-Danlos Syndrome) have caused cervical spine instability. A thicker Longus Colli muscle may offer the clue necessary to help isolate cervical spine instability as opposed to other causes for your dizziness. The thicker muscle may indicate that the cervical spine ligaments are weak, your cervical vertebra is out of place, and something is pressing on your nerves and arteries causing a dizzy situation.


Part 4 Surgical Recommendations for Cervicogenic Vertigo


A December 2021 paper in the journal Audiology Research (20) discusses the surgical options for cervicogenic vertigo. “A variety of invasive interventions for cervicogenic vertigo have been explored, including cervical medial branch blocks, percutaneous cervical nucleoplasty, radiofrequency ablation nucleoplasty, percutaneous laser disc decompression, intervertebral disc replacement, and surgery for cervical spondylosis or disc herniation. Case series of the various invasive treatments for presumed cervicogenic vertigo generally report variable outcomes. Given the uncertainty in establishing the diagnosis and the risks of invasive procedures, we would view invasive procedures as a last-resort approach.”

Coblation nucleoplasty

Coblation nucleoplasty is a disc decompression procedure to take pressure off of the nerves. It is an option for minimally invasive spinal procedures such as microdiscectomy and laminectomy.

A June 2023 paper in the Journal of Clinical Medicine (21) compared the effectiveness of coblation nucleoplasty with prolonged conservative treatment for cervical discogenic dizziness. The researchers here looked for outcomes that provided minimal clinically important differences (MCID) and patient-acceptable symptom state (PASS) after surgery.

There were 61 patients in this study, 40 patients underwent cervical coblation nucleoplasty, while the remaining 21 patients refused surgery and received continued conservative treatment. Conservative care treatment includes exercise, vestibular rehabilitation, drug therapy, posture control, and physical therapy.  Both groups of patients were followed for 12 months post-treatment.

What the researchers reported was:

  • Dizziness intensity, dizziness frequency, pain, function, and disability scores were significantly improved from the baseline at all follow-up time points in both treatment groups, except:
    • The conservative care group showed no significant improvement in dizziness frequency at 6 and 12 months after surgery.
  • The achieved rates for minimal clinically important differences (MCID) and patient acceptable symptom state (PASS) in all patient reporting were significantly higher in the surgery group than those in the conservative treatment group at 12 months after surgery.

Anterior cervical discectomy and fusion (ACDF)

A January 2023 study published in the journal Frontiers in Surgery (22) investigated the role of anterior cervical discectomy and fusion (ACDF) in alleviating symptoms in patients with cervical vertigo associated with cervical instability.

  • The study was of 79 anterior cervical discectomy and fusion patients who had their surgery between January 2011 and December 2019 and followed up for more than two years.
  • Noted was that patients with C3/4 instability suffered more severe vertigo than patients at other cervical levels.
  • On average disability and pain scores were significantly reduced after ACDF and this was sustained within two years after surgery.
  • Although there was no statistical difference in the ratio of patients with vertigo relief, patients with one-level cervical instability demonstrated a more rapid recovery than patients with multi-level cervical instability
  • The researchers also noted improvement in other symptoms such as neck and occipital pain, gastrointestinal discomfort, nausea, vomiting, tinnitus, palpitations, headache, and blurring of vision after surgery.

Part 5: Cervical instability and vertigo – non-surgical options that focus on the cervical ligaments


The cervical ligaments are strong bands of tissues that attach one cervical vertebra to another. In this role, the cervical ligaments become the primary stabilizers of the neck. When the cervical ligaments are healthy, your head movement is healthy, pain-free, and non-damaging. When the ligaments are suffering from degenerative wear and tear or excessive looseness or laxity that prevents the ligaments from holding the vertebrae together, the ligaments lose their ability to control the proper motion of your head. The head begins to move in a destructive, degenerative manner on top of your neck. When this occurs the cervical neck ligaments cry out and you feel pain and you can develop the symptoms of cervical vertigo and dizziness.

  • Most of the nerve endings that trigger neck pain are located in the ligaments.
  • When a patient comes into our clinics with cervical spine pain and symptoms already outlined in this article, we are attuned to the fact that the actual pain stems from the nerve endings in the ligaments.
  • So we listen to what the neck is telling us:
  • There is a problem with stretched-out or damaged ligaments.

In the journal, Medical Hypothesis,(23) researchers and clinicians made a connection that the loss of flexibility of the posterior longitudinal ligament in the neck was a compounding factor in cervical dizziness.

Here are the learning points of this study and what the doctors were looking for in the treatment of cervical disorders, such as vertigo, headache, and dizziness.

  • Some patients were helped by undergoing routine anterior cervical decompression and fusion plus posterior longitudinal ligament (PLL) resection. The removal of the ligament in the neck region.
  • If the ligaments are so important, why remove any part of a ligament? In this study, the doctors hypothesized that the sympathetic nerve innervations (nerve signals or messages) in the cervical posterior longitudinal ligament may be the cause of vertigo.

So what does this mean to you? 

  • With fusion surgery, doctors recommend the removal of the posterior longitudinal ligament because if you leave it behind, it can cause dizziness post-fusion. How? Because it is still damaged and still sending pain signals that disrupt the nerves and cause dizziness.
  • If you have a fusion, the rods and screws replace the ligament and ligaments of the neck as the main neck stabilizer.

But what if fusion is not what you want? Can this ligament be repaired to not send pain signals and cause dizziness? The answer is for many people, yes.

Treating cervical ligaments – published research from Caring Medical

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment for difficult-to-treat musculoskeletal disorders including problems created by neck instability. Above, we discussed our 2014 research headed by Danielle R. Steilen-Matias, PA-C, (12) we also noted that when the cervical ligaments are injured, they become stretched out and loose. This allows for excessive abnormal movement of the cervical vertebrae.

  • In the upper cervical spine (C0-C2), this can cause symptoms such as nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches.

Treating and stabilizing the cervical ligaments can alleviate the problems of cervical vertigo by preventing excessive abnormal vertebrae movement, the development or advancement of cervical osteoarthritis, and the myriad of problematic symptoms they cause.

Disabling dizziness from neck instability treated successfully with Prolotherapy

In this video, a patient shares his experience with dizziness and light sensitivity coming from neck instability, and treatment with Prolotherapy here at the Hauser Neck Center. His story is similar to many people who we speak to and see here for care. **DISCLAIMER: As with any medical treatment, no guarantees or claims of cures are made as to the extent of the response to treatment that every person experiences. Every therapy/treatment has patients who experience varying levels of success and failure. Results may not be the same from patient to patient, even with a similar diagnosis, as the body’s internal status is unique to each individual.

Regenerative Medicine Injections | Caring Cervical Realignment Therapy

Prolotherapy is an injection technique that stimulates the repair of unstable, torn, or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertebrae, which can then restrict blood flow to the brain, pinch on nerves (a pinched nerve causing vertigo), and cause other symptoms associated with joint instability, including cervical instability.

Non-surgical treatment – Cervical Spine Stability and Restoring Lordosis -Making a case for regeneration and repair of the spinal ligaments

Above we spoke about the vertebrae not being in the right place and this is caused by cervical spine ligament laxity or damage. The muscles of the neck may then spasm and thicken as a result of the muscle trying to do a job it was really not intended to do. Hold the cervical vertebrae in place. We also spoke about people who suffer dizziness when they move their heads a certain way.

Look at these images below. When the patient looks down, there is a 6 mm (about 2/10ths of an inch) space between the C1-C2. There is room for some vessels and nerves to get through. When the same patient looks up, 0 mm or NO SPACE. Everything in between gets pinched.

The space between C1 and C2 varies with head movement.

In this section, we are going to talk about the realistic non-surgical options for the treatment of cervical spine instability and compressed cervical arteries and their related symptoms.

Actual Prolotherapy treatment

This video jumps to 1:05 where the actual treatment begins.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

Caring Cervical Realignment Therapy (CCRT)

As we discussed in reviewing the research above, our goal is to provide long-term solutions to the problems and symptoms of chronic neck pain and instability such as headaches, dizziness, vertigo, lightheadedness, imbalance, and a host of other symptoms attributed to neck injuries.

Caring Cervical Realignment Therapy combines individualized protocols to objectively document spinal instability, strengthen weakened ligament tissue that connects vertebrae, re-establish normal biomechanics, and encourage the restoration of lordosis. This is our treatment method of moving towards putting a patient’s cervical spine back into place.

Through extensive research and patient data analysis, it became clear that in order for patients to obtain long-term cures (approximately 90% relief of symptoms) the re-establishment of some lordosis, (the natural cervical spinal curve) in their cervical spine is necessary. Once spinal stabilization was achieved with Prolotherapy and the normalization of cervical forces by restoring some lordosis, lasting relief of symptoms was highly probable.

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability. Cervical instability is a progressive disorder causing a normal lordotic curve to end up as an “S” or “Snake” curve with crippling degeneration.

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability. Cervical instability is a progressive disorder causing a normal lordotic curve to end up as an “S” or “Snake” curve with crippling degeneration.

Treatments for cervical spine realignment – restoring the curve without surgery

When we start looking at the most recent research papers surrounding treatments for cervical spine realignment, we often find ourselves reading a lot of new research on cervical spine surgery procedures. Non-surgical treatments for cervical spine realignment are, for the most part, fewer and far between. There is a rush in medicine to surgically correct cervical spine abnormalities including the loss of the natural cervical spine curve. In our office, we rush more to non-surgical applications to help the patient with cervical spine instability and abnormal curvature of the spine. But what if you were told surgery should be strongly considered?

A February 2017 study in the European Journal of Physical and Rehabilitation Medicine (24) investigated the immediate and long-term effects of a 1-year multimodal (multi-treatment) program, with the addition of cervical lordosis restoration and anterior head translation (Forward Head Posture) correction, on the severity of dizziness, disability, cervicocephalic kinesthetic sensibility (proper head orientation), and cervical pain in patients with cervicogenic dizziness.

Patients were divided into two groups, both groups received therapy and exercise programs, and one group received a cervical neck traction device.  At 10 weeks, the group analysis showed equal improvements in dizziness outcome measures, pain intensity, head repositioning accuracy, the severity of dizziness, dizziness frequency, and neck pain.

At 1-year follow-up, the between-group analysis identified statistically significant differences for all of the measured variables including anterior head translation, cervical lordosis, the severity of dizziness, dizziness frequency, and neck pain, indicating greater improvements in the traction group. The results lead the researchers to conclude that “appropriate physical therapy rehabilitation for cervicogenic dizziness should include structural rehabilitation (traction) of the cervical spine (lordosis and head posture correction), as it might lead to greater and longer-lasting improved function.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

Please see related articles:

We hope you found this article informative and that it helped answer many of the questions you may have surrounding Cervical Vertigo and Cervicogenic Dizziness. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Contact the Hauser Neck Center team

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This article was updated January 11, 2024

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