What is the workup and treatment for cervicogenic vertigo?

Workup and Treatment for Cervicogenic Vertigo

Diagnostic Approach

Cervicogenic dizziness is a diagnosis of exclusion that requires correlating neck pain with dizziness symptoms while systematically ruling out other vestibular and neurological disorders through history, examination, and vestibular function testing. 1

Clinical Criteria for Diagnosis

The diagnosis is characterized by:

• Dizziness and dysequilibrium associated with neck pain in patients with cervical pathology 1
• Symptoms triggered by rotation of the head relative to the body while upright (as opposed to vertigo triggered by changes in head position relative to gravity, which suggests BPPV) 2
• Absence of true spinning vertigo, which makes peripheral vestibular causes like BPPV, Menière's disease, or vestibular neuritis unlikely 3
• No associated hearing loss or tinnitus, which excludes Menière's disease and other otologic causes 3

Essential Exclusions Before Diagnosis

You must systematically exclude:

Benign Paroxysmal Positional Vertigo (BPPV):

• Perform Dix-Hallpike maneuver to rule out posterior canal BPPV 2
• Perform supine roll test to rule out lateral canal BPPV 2
• BPPV is distinguished by vertigo provoked by positional changes relative to gravity (lying down, rolling over, bending down, tilting head back) 2

Central Nervous System Disorders:

• Assess for gaze-evoked nystagmus, severe postural instability, and additional neurological signs 2
• Note that imaging has extremely low diagnostic yield (<1% for CT, 4% for MRI) in nonspecific dizziness without vertigo, ataxia, or neurologic deficits 3

Other Vestibular Disorders:

• Vestibular neuritis and labyrinthitis - typically present with acute, severe vertigo, not chronic daily dizziness 2
• Menière's disease - requires episodic vertigo with hearing loss and tinnitus 2, 3

Migraine-Associated Dizziness:

• Accounts for 14% of adult vertigo cases and can present without headache 3
• Consider even without classic migraine symptoms in chronic dizziness 3

Anxiety/Panic Disorder:

• Commonly presents with chronic nonspecific dizziness, especially if accompanied by dyspnea 2, 3

Vertebrobasilar Insufficiency:

• Distinguished by nystagmus that does not fatigue and is not easily suppressed by gaze fixation 2
• Episodes typically last less than 30 minutes with no associated hearing loss 2

Diagnostic Testing

Vestibular Function Testing:

• Should be performed when clinical presentation is atypical, Dix-Hallpike testing is equivocal, or additional symptoms suggest concurrent vestibular disorders 2
• May identify coexisting vestibular pathology present in 31% to 53% of patients with suspected cervical involvement 2

Imaging:

• Generally not recommended for isolated nonspecific dizziness without neurological deficits, given extremely low yield 3
• Consider only if red flags for central pathology are present 3

Treatment Algorithm

Manual therapy combined with vestibular rehabilitation exercises is the most effective treatment for confirmed cervicogenic dizziness. 3, 4

Primary Treatment Approach

Manual Therapy (Spinal Mobilization and Manipulation):

• Moderate evidence supports manual therapy as first-line treatment for cervicogenic dizziness 4
• Includes mobilization and/or manipulation of the cervical and thoracic spine 2
• Studies report improvement in dizziness, postural stability, joint positioning, range of motion, muscle tenderness, and neck pain 4
• Should be performed by trained practitioners to avoid complications 5

Vestibular Rehabilitation:

• Recommended in conjunction with manual therapy, though evidence for synergistic effects is limited 4
• Includes exercises for balance and gait training 2
• The American Physical Therapy Association gives level B (moderate evidence) for addressing cervical and thoracic spine dysfunction with manual treatment 2

Treatment for Specific Subtypes

Proprioceptive Cervical Vertigo:

• Manual therapy is specifically recommended 6
• Combination of manual therapy and vestibular rehabilitation 1, 4

Barré-Lieou Syndrome (Cervical Spondylosis with Sympathetic Involvement):

• Anterior cervical surgery or percutaneous laser disc decompression for severe cases 6
• Conservative management with manual therapy initially 6

Rotational Vertebral Artery Vertigo:

• Identify exact area of arterial compression through MRA, CTA, or DSA 6
• Decompressive surgery when compression is confirmed 6
• This is a rare entity requiring specialized vascular imaging 6

Treatment Duration and Follow-up

• Improvement typically seen within 4 weeks of treatment 5
• Persistent symptoms warrant reevaluation for alternative diagnoses 2
• Some patients achieve complete resolution with normalization of cervical motility 7

Common Pitfalls to Avoid

Critical Warning: Never perform or allow self-manipulation of the cervical spine, as this can precipitate acute cervicogenic dizziness 5

Do not:

• Diagnose cervicogenic dizziness without first excluding BPPV through proper positional testing 2
• Overlook concurrent vestibular pathology, which is present in up to 53% of cases 2
• Apply canalith repositioning procedures (Epley, Semont maneuvers) to cervicogenic dizziness, as these are specific to BPPV 2
• Order extensive imaging without neurological red flags given the low diagnostic yield 3

Do:

• Counsel patients to seek professional evaluation rather than self-treating neck issues 5
• Consider that treatment failures may indicate misdiagnosis or concurrent vestibular disorders 2
• Reassess if symptoms persist beyond 4 weeks of appropriate treatment 5