How should I evaluate and manage a patient with suspected cervicogenic dizziness presenting with light‑headedness associated with neck pain, stiffness, or limited cervical range of motion?

Cervicogenic Dizziness: Evaluation and Management

Diagnosis

Cervicogenic dizziness is a diagnosis of exclusion requiring systematic elimination of vestibular, central, and vascular causes before attributing symptoms to cervical spine dysfunction. 1

Key Diagnostic Features

• The hallmark trigger pattern is dizziness provoked by rotation of the head relative to the body while upright—NOT by changes in head position relative to gravity (which would indicate BPPV). 1

• Episodes range from brief to prolonged, unlike BPPV which resolves within 60 seconds. 1

• Patients present with light-headedness, dysequilibrium, and associated neck pain, stiffness, or limited cervical range of motion. 2, 3

• Clinical signs include tenderness in the cervical spine (midline, paraspinal, and suboccipital regions), weakness with cervical and upper extremity myotome testing, limitation of cervical motion, pain with cervical motion, and possible radicular symptoms. 4

Mandatory Exclusions Before Diagnosis

Peripheral vestibular causes:

• Perform bilateral Dix-Hallpike maneuver to rule out BPPV—positive findings show torsional upbeating nystagmus with 5-20 second latency, crescendo-decrescendo pattern, fatigability, and resolution within 60 seconds. 1

Central causes requiring urgent neuroimaging:

• Severe postural instability with falling, new-onset severe headache with vertigo, focal neurological deficits, downbeating or direction-changing nystagmus, or any additional neurological symptoms mandate immediate MRI brain without contrast. 1, 5

Vascular causes:

• Vertebrobasilar insufficiency can present with isolated vertigo attacks lasting <30 minutes and may precede stroke by weeks or months; screen for diplopia, perioral numbness, bilateral sensory deficits, and drop attacks. 1, 6

• In patients >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke), obtain MRI even with normal neurologic exam, as 11-25% may harbor posterior circulation stroke. 5

Treatment

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

Primary Treatment Components

• Manual therapy targeting cervical spine dysfunction forms the foundation of treatment. 1, 2

• Vestibular rehabilitation exercises should be incorporated as adjunctive therapy to address proprioceptive dysfunction and aberrant cervical afferent signaling. 1, 6

• Cervical stability exercises—progressive strengthening and stabilization targeting the cervical spine—are essential for long-term resolution. 1

• Avoid vestibular suppressant medications (antihistamines, benzodiazepines), as they do not address the underlying mechanical pathology and may delay central compensation. 1, 6

Imaging Decisions

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

• Obtain MRI or CT only if red flags are present: vascular dissection concerns, neurologic deficits, trauma, or failure to respond to appropriate treatment after 6-8 weeks. 1, 6

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. 1

Expected Outcomes and Follow-Up

• Treatment duration typically ranges from 4 weeks to 8 months depending on severity. 1

• Track Dizziness Handicap Inventory (DHI) scores—successful treatment shows reduction from moderate handicap (50) to minimal handicap (10 or less). 1, 7

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

• If symptoms persist or worsen, reconsider the diagnosis and evaluate for missed central or vestibular pathology. 1

Common Pitfalls to Avoid

• Failing to systematically exclude BPPV, vestibular migraine, Ménière's disease, and posterior circulation stroke before diagnosing cervicogenic dizziness. 3

• Ordering imaging without red flags—this yields minimal diagnostic benefit and often produces incidental findings that do not change management. 1

• Prescribing vestibular suppressants, which are ineffective for cervicogenic dizziness and may impair vestibular compensation. 1, 6

• Overlooking whiplash-associated disorder or cervical arterial dysfunction, which share common injury mechanisms with cervicogenic dizziness but require different management. 4, 3