In an adult with recent neck pain or cervical trauma presenting with light‑headedness and unsteadiness that worsens with neck movement and no vestibular, cardiac, neurologic, or metabolic cause, how should I evaluate and manage suspected cervicogenic dizziness?

Cervicogenic Dizziness: Evaluation and Management

In an adult with recent neck pain or cervical trauma presenting with light-headedness and unsteadiness worsened by neck movement—after excluding vestibular, cardiac, neurologic, and metabolic causes—cervicogenic dizziness is a diagnosis of exclusion that should be managed with manual therapy and vestibular rehabilitation rather than imaging or medications. 1, 2

Clinical Diagnosis

Cervicogenic dizziness is defined by the correlation of dizziness/disequilibrium episodes with neck pain in patients with cervical pathology, triggered specifically by neck movement rather than head position changes relative to gravity. 1, 2, 3

Key Distinguishing Features

• Symptom trigger pattern: Dizziness provoked by rotation of the head relative to the body while upright (cervicogenic) versus dizziness triggered by changes in head position relative to gravity (BPPV). 1
• Associated neck pain: Concurrent or preceding neck pain, restricted cervical range of motion, and cervical muscle hypertonicity are characteristic. 2, 3, 4
• Duration: Symptoms typically last minutes to hours, not seconds (which would suggest BPPV) or days (which would suggest vestibular neuritis). 5

Critical Exclusions Required Before Diagnosis

You must systematically rule out competing diagnoses:

• BPPV: Perform bilateral Dix-Hallpike maneuver; cervicogenic dizziness will be negative. 5, 2, 3
• Vestibular neuritis: Check for unidirectional horizontal nystagmus and abnormal head-impulse test; cervicogenic dizziness has normal vestibular function tests. 5, 3
• Vertebrobasilar insufficiency: Assess for diplopia, perioral numbness, bilateral sensory deficits, and drop attacks; obtain vascular imaging if suspected. 6, 1, 3
• Vestibular migraine: Screen for migraine history, photophobia, and phonophobia during episodes. 1, 5
• Posterior circulation stroke: In patients >50 years with vascular risk factors, obtain MRI brain without contrast even with normal neurologic exam. 5

Imaging Recommendations

Routine imaging is NOT indicated for cervicogenic dizziness unless red-flag features are present. 1

When Imaging Is NOT Needed

• Typical cervicogenic pattern (dizziness with neck movement, associated neck pain, normal vestibular testing) without red flags requires no imaging. 1, 5
• Degenerative cervical changes on imaging do not correlate with symptoms and are present in 85% of asymptomatic individuals over 30 years. 7

When Imaging IS Indicated

Obtain MRI cervical spine without contrast only if: 6, 1

• Symptoms persist >6–8 weeks despite appropriate conservative therapy
• Red-flag signs present: constitutional symptoms, fever, weight loss, elevated inflammatory markers (ESR, CRP), known malignancy, immunosuppression, IV drug use, progressive neurologic deficits, or vertebral-body tenderness 6
• Concern for vascular dissection: unilateral headache with neck pain warrants CTA or MRA head and neck 1
• Concern for craniocervical instability: subtle anterolisthesis or abnormal clivo-axial angle on plain radiographs 8

CT head has <1% diagnostic yield for isolated dizziness and should be avoided. 5

Management Algorithm

First-Line Treatment

Combine manual therapy with vestibular rehabilitation as primary treatment. 1, 2, 3

1. Manual therapy: Spinal manipulation, soft tissue release, and cervical mobilization to address restricted range of motion and muscle hypertonicity. 2, 4, 9

2. Vestibular rehabilitation: Habituation exercises, gaze stabilization, and balance retraining to promote central compensation. 1, 5, 2

3. Treatment duration: Expect 3–4 months of therapy; most patients show improvement within this timeframe. 2, 8, 9

Medications to AVOID

• Vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) should NOT be routinely used because they do not address the underlying cervical proprioceptive dysfunction and may delay central compensation. 1, 5

Special Considerations

• Elderly patients with cervical arthritis: Increased fall risk and persistent postural abnormalities require modified treatment approaches and home safety assessment. 1
• Patients with cervical stenosis, severe rheumatoid arthritis, or ankylosing spondylitis: Manual therapy techniques must be modified to avoid neurologic injury. 1
• Post-trauma patients: Exclude cervical arterial dissection before initiating manual therapy if trauma occurred within 6 weeks. 3

Common Diagnostic Pitfalls

• Relying on imaging findings alone: Degenerative changes are ubiquitous in asymptomatic adults and do not confirm cervicogenic dizziness. 7
• Failing to perform vestibular testing: Cervicogenic dizziness requires normal vestibular function tests; abnormal results indicate a different diagnosis. 2, 3
• Assuming normal neurologic exam excludes stroke: 75–80% of posterior circulation strokes lack focal deficits; obtain MRI in high-risk patients regardless of exam. 5
• Overlooking medication side effects: Antihypertensives, sedatives, and anticonvulsants are leading reversible causes of chronic dizziness. 5
• Missing vestibular migraine: This accounts for 14% of all vertigo cases but is markedly under-recognized, especially in younger adults. 5

Expected Outcomes

• Success rate: When diagnosed correctly, cervicogenic dizziness responds well to combined manual therapy and vestibular rehabilitation, with most patients improving within 3–4 months. 2, 9
• Recurrence: Patients should be counseled about potential recurrence with future neck trauma or poor posture. 9
• Follow-up: Reassess at 4–6 weeks; if no improvement, reconsider the diagnosis and exclude competing etiologies. 2, 3