Cervicogenic Dizziness

Definition and epidemiology

Cervicogenic dizziness is dizziness and unsteadiness that occur with neck pain or dysfunction of the cervical spine and are thought to originate from disordered proprioceptive input (joint and muscle position sense) from the neck. It is a contested diagnosis in both vestibular and musculoskeletal settings: there are no specific diagnostic criteria and no gold-standard test, and the diagnosis can only be made once other causes have been excluded (De Hertogh et al., 2025; Reiley et al., 2017). Brandt and Bronstein (2001) described ‘cervical vertigo’ as a controversial clinical entity, noting that many patients given this label have another explanation for their symptoms, and suggested that the term, used without qualification, should be reserved for a proprioceptive mechanism.

There are no reliable data on the frequency of cervicogenic dizziness itself. Published figures range from 5-6% in ENT clinics to 40% in patients with neck pain, and 43% of people with long-standing neck pain have been reported to experience dizziness (De Hertogh et al., 2025). The wide range also reflects how loosely the condition is defined. Some authors use a broad definition that includes vascular causes (De Hertogh et al., 2025). This article uses the term in its proprioceptive sense and treats vascular causes such as vertebrobasilar insufficiency and arterial dissection as urgent differential diagnoses. For a general classification of dizziness, see the introduction to vertigo and balance disorders.

Symptoms and signs

Symptoms may be described as spinning, light-headedness or unsteadiness, and they occur together with neck pain and restricted neck movement. A close temporal relationship between the dizziness and the onset of neck symptoms is required: cervicogenic dizziness should not be considered in the absence of neck pain. Symptoms worsen with movements that provoke neck pain and ease when the neck pain settles. The complaint may last from days to years, while individual episodes last minutes to hours (Reiley et al., 2017). Autonomic symptoms such as palpitations, nausea and vomiting may also occur (De Hertogh et al., 2025).

Examination may show reduced neck range of motion, tenderness over the upper cervical joints and tight neck muscles. In traumatic neck pain, particularly after whiplash injury, dizziness has been described together with unsteadiness, visual disturbances such as blurring or difficulty focusing when reading, and impaired sensorimotor control (Treleaven, 2017). These deficits can be measured in head position sense, eye movement control and standing balance. Hearing loss, aural fullness, pulsatile tinnitus or neurological symptoms are not part of cervicogenic dizziness, and any of them should prompt a search for another diagnosis.

Causes and risk factors

The neck, especially the upper cervical region, is rich in muscle spindles and joint receptors. Together with the vestibular and visual systems, this proprioceptive information tells the brain where the head and trunk are in space. According to the sensory mismatch theory, when neck proprioception is disturbed it conflicts with vestibular and visual information, resulting in postural instability and dizziness. In chronic cases, maladaptive sensory reweighting in the central nervous system has been proposed as a reason why recovery can be slow (De Hertogh et al., 2025).

The best described background is whiplash and other neck trauma (Treleaven, 2017); degenerative neck disease and chronic neck pain have also been linked with the condition. On the other hand, Brandt and Bronstein (2001) point out that illusions of self-motion are much harder to evoke by neck stimulation than by vestibular or visual stimulation, suggesting that the proprioceptive mechanism may be weaker than it first appears. The coexistence of neck pain and dizziness does not prove causation: neck pain has been reported in 37.5% of patients with BPPV and 46.7% of those with other causes of dizziness (De Hertogh et al., 2025). Not every dizzy patient with neck pain should therefore be labelled as cervicogenic.

Audiological and clinical assessment

Because there is no specific test for cervicogenic dizziness, assessment has two stages: urgent and treatable causes are excluded first, and then findings that support a contribution from the neck are sought. Reiley et al. (2017) recommend treating any clear vestibular disorder first and confirming a cervicogenic diagnosis only if dizziness persists once coexisting problems have been treated. The audiologist’s role is to document normal hearing and peripheral vestibular function and to make sure BPPV is not missed on positional testing.

• Pure-tone and speech audiometry: hearing is not affected in cervicogenic dizziness, and thresholds are within age-appropriate limits. Asymmetric sensorineural loss, fluctuating hearing or new unilateral tinnitus point to another diagnosis.
• Positional tests: Dix-Hallpike and supine roll tests should be performed in every patient, and post-traumatic BPPV in particular should be ruled out at the outset (De Hertogh et al., 2025). If neck movement is limited, the tests can be adapted on the couch with the head supported.
• Vestibular tests: the video head impulse test (vHIT), caloric testing and vestibular evoked myogenic potentials (VEMPs) are normal in cervicogenic dizziness. An abnormal result indicates a peripheral or central vestibular disorder. Neck pain and range of motion should be checked before vHIT, and the test should not be performed if arterial dissection is suspected.
• Neck torsion tests: the head is held still while the trunk is rotated, and dizziness and nystagmus are looked for. In a study comparing patients with BPPV, the neck torsion test had a positive likelihood ratio of 9 (Reiley et al., 2017); torsion nystagmus faster than 2 degrees per second has been reported to have a sensitivity of 72% and specificity of 92% (De Hertogh et al., 2025).
• Smooth pursuit neck torsion test: smooth pursuit gain with the trunk rotated is compared with gain in the neutral position (Tjell and Rosenhall, 1998). Although differences have been shown after whiplash, up to half of people without neck problems may test positive, and the test is not currently considered useful for diagnosis on its own (De Hertogh et al., 2025; Reiley et al., 2017).
• Cervical joint position error test: with the eyes closed, the head is rotated and returned to the starting position, and the error is measured in degrees. A negative result has a likelihood ratio of 0.15, so the test is more useful for ruling the diagnosis out (Reiley et al., 2017). With a 4.5° threshold, sensitivity is 92% and specificity 54% (De Hertogh et al., 2025).
• Head-neck differentiation test: dizziness provoked by rotating the trunk with the head stabilised suggests a cervical source, whereas dizziness when the head and trunk rotate together suggests a vestibular contribution; its diagnostic value has not yet been studied (Reiley et al., 2017).

The first priority is the urgent differential diagnosis. Vertebrobasilar insufficiency and cervical (vertebral or carotid) artery dissection can begin with neck pain and dizziness. Dizziness is the only symptom in fewer than 1% of dissections (Reiley et al., 2017), so accompanying neurological symptoms must be asked about in every patient. The International IFOMPT Cervical Framework recommends adapting the history and physical examination to the possibility of vascular pathology before any manual treatment of the neck (Rushton et al., 2023). Red flags include sudden severe neck pain or headache unlike any before, double vision, difficulty speaking or swallowing, numbness or weakness in the face or limbs, drop attacks, gait ataxia, central eye signs such as direction-changing or vertical nystagmus, and Horner syndrome. Any of these requires emergency assessment; see central vertigo for details.

The conditions most often confused with cervicogenic dizziness in clinic are BPPV, vestibular migraine and Persistent Postural-Perceptual Dizziness (PPPD). Vestibular migraine has been suggested as the most likely cause in patients with dizziness and neck pain (De Hertogh et al., 2025). After trauma, labyrinthine concussion, vestibular neuritis and Ménière’s disease also belong in the differential diagnosis (Reiley et al., 2017).

Treatment and audiological rehabilitation

Treatment first targets any coexisting cause: a repositioning manoeuvre for BPPV, or migraine treatment recommended by the doctor for vestibular migraine. In cervicogenic dizziness the mainstay is treatment of the neck problem: manual therapy (mobilisation, manipulation and sustained natural apophyseal glides, SNAGs), neck exercises and sensorimotor control training, planned by a physiotherapist. A vascular risk assessment should precede any manual treatment of the neck (Rushton et al., 2023). Whether medication is needed is a decision for the doctor.

A systematic review by Lystad et al. (2011) of 13 studies, five randomised controlled trials and eight uncontrolled cohorts, found moderate evidence supporting manual therapy but insufficient evidence on combining manual therapy with vestibular rehabilitation. A more recent meta-analysis of 13 randomised controlled trials (898 patients) rated the evidence as moderate for manual therapy alone and very low certainty for manual therapy combined with exercise (De Vestel et al., 2022). In a randomised trial of 86 patients with chronic cervicogenic dizziness, two different manual therapy techniques reduced dizziness frequency and Dizziness Handicap Inventory scores compared with placebo, with the benefit still present at 12 months and no adverse effects reported (Reid et al., 2015). Tailored sensorimotor control programmes have also been reported to be beneficial (De Hertogh et al., 2025).

Vestibular rehabilitation is added when a vestibular component is found or when unsteadiness and visual motion sensitivity are prominent; gaze stabilisation, balance and habituation exercises can be combined with neck exercises. Evidence for an added benefit from this combination is limited (De Vestel et al., 2022; Lystad et al., 2011). The audiologist should share vestibular test results with the physiotherapist and use tools such as the Dizziness Handicap Inventory and the Activities-specific Balance Confidence Scale at baseline and follow-up. If symptoms persist despite treatment, new neurological signs appear or hearing changes, the diagnosis should be reconsidered.

Impact on quality of life and advice

Cervicogenic dizziness is not life-threatening, but combined with neck pain it can limit work, driving, prolonged screen use and sport. Diagnostic uncertainty and being passed between specialists can add to anxiety. If avoidance of movement and anxiety become prominent with long-lasting symptoms, the person should also be assessed for PPPD, and cognitive behavioural approaches can then be added to treatment.

Practical advice: if your neck pain and dizziness started together, tell your doctor and audiologist clearly, and note which movements bring the symptoms on. Before any neck manipulation, tell the practitioner whether you have any of the warning signs listed above. If you work in the same posture for long periods, take regular breaks and do the neck exercises you have been given. Do not drive while dizzy, and hold the handrail on stairs. Exercises may increase symptoms slightly at first; if severe pain or a new symptom appears, stop and seek advice.