What is the diagnosis and treatment for cervicogenic dizziness (dizziness caused by cervical spine dysfunction)?

Cervicogenic Dizziness: Diagnosis and Treatment

Diagnosis

Cervicogenic dizziness is a diagnosis of exclusion characterized by dizziness and dysequilibrium associated with neck pain in patients with cervical spine dysfunction, diagnosed only after systematically ruling out vestibular, central, and vascular causes. 1, 2

Key Distinguishing Clinical Features

• Trigger pattern: Symptoms are provoked by rotation of the head relative to the body while upright, NOT by changes in head position relative to gravity (which would suggest BPPV). 1

• Associated symptoms: Neck pain must be present concurrently with dizziness; cervical or cervicothoracic pain and occipital-temporal headaches are common. 3, 4

• Duration: Episodes can range from brief to prolonged, unlike BPPV which lasts <1 minute. 5, 4

Mandatory Exclusion of Other Diagnoses

Before diagnosing cervicogenic dizziness, you must systematically exclude:

Peripheral vestibular causes:

• Perform bilateral Dix-Hallpike maneuver to rule out BPPV (the most common cause of vertigo at 42% of cases). 5
• Positive BPPV shows torsional and upbeating nystagmus with 5-20 second latency, crescendo-decrescendo pattern, fatigability, and resolution within 60 seconds. 5
• Assess for Ménière's disease (fluctuating hearing loss, tinnitus, aural fullness) and vestibular neuritis (acute severe vertigo lasting days). 5

Central causes requiring urgent neuroimaging:

• Severe postural instability with falling. 5, 1
• New-onset severe headache with vertigo. 5
• Any additional neurological symptoms (dysarthria, dysmetria, dysphagia, sensory/motor deficits, diplopia). 5
• Downbeating nystagmus on Dix-Hallpike without torsional component. 5
• Purely vertical nystagmus without torsional component. 5
• Baseline nystagmus present without provocative maneuvers. 5
• Nystagmus that does not fatigue and is not suppressed by gaze fixation. 5, 1

Vascular causes:

• Vertebrobasilar insufficiency can present with isolated vertigo attacks lasting <30 minutes and may precede stroke by weeks or months. 5, 1
• If unilateral headache and neck pain raise concern for cervical arterial dissection, obtain CTA or MRA. 6, 1

Other considerations:

• Vestibular migraine (lifetime prevalence 3.2%, accounts for 14% of vertigo cases) presents with motion intolerance, photophobia, and stable or absent hearing loss. 5
• Consider postural orthostatic tachycardia syndrome (POTS) with tilt table testing if appropriate. 3

Imaging Recommendations

• Routine imaging is NOT indicated for cervicogenic dizziness without red flags, as imaging has no diagnostic value and frequently shows abnormalities in asymptomatic patients. 6, 1

• Obtain MRI or CT only if red flags are present: vascular dissection concerns, neurologic deficits, trauma, or failure to respond to appropriate treatment. 1

• Dynamic cervical radiographs may reveal cervical instability or loss of normal lordosis in select cases. 3, 7

Treatment

The most effective treatment combines manual therapy with vestibular rehabilitation exercises and cervical stabilization, avoiding vestibular suppressant medications. 5, 1, 4

First-Line Conservative Management

• Manual therapy: Gentle manual techniques including spinal manipulation and soft tissue release directed at cervical dysfunction. 3, 4, 7

• Vestibular rehabilitation exercises: These are beneficial as adjunctive therapy and should be incorporated into the treatment plan. 1, 4

• Cervical stability exercises: Progressive strengthening and stabilization exercises targeting the cervical spine. 3, 4

• Structural rehabilitation: For patients with hypolordotic cervical spine and anterior head translation, cervical extension traction (such as Denneroll™) added to multimodal therapy produces superior long-term outcomes at 1-year follow-up compared to multimodal therapy alone. 8

What NOT to Do

• Do NOT routinely prescribe vestibular suppressant medications (antihistamines, benzodiazepines) for cervicogenic dizziness, as they prevent central compensation. 5, 1

• Do NOT obtain neuroimaging in patients meeting diagnostic criteria without red flags. 5, 1

Special Populations Requiring Modified Approaches

• Patients with cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies, or ankylosing spondylitis require modified treatment approaches. 1

• Elderly patients with cervical arthritis have increased fall risk and may need more cautious progression. 1

• Patients with impaired mobility, CNS disorders, or lack of home support require assessment of modifying factors. 5

Expected Outcomes and Follow-Up

• Treatment duration typically ranges from 4 weeks to 8 months depending on severity. 3, 7

• Dizziness Handicap Inventory (DHI) scores should be tracked, with successful treatment showing reduction from moderate handicap (50) to minimal handicap (10 or less). 3

• Reassess within 1 month to document resolution or persistence of symptoms. 5

• If symptoms persist or worsen, reconsider the diagnosis and evaluate for missed central or vestibular pathology. 5, 2

Critical Pitfall to Avoid

Approximately 10% of cerebellar strokes present similarly to peripheral vestibular disorders, and isolated transient vertigo may precede vertebrobasilar stroke by weeks or months. 5, 1 Any red flags demand immediate neuroimaging with MRI brain including diffusion-weighted imaging. 5