Timothy C. Hain, MD • Page last modified: February 5, 2021
Cervicogenic dizziness is dizziness that is caused by the neck. Typically it s provoked by a particular neck posture no matter what the orientation of the head is to gravity. For example, dizziness provoked associated with a certain head position about the vertical axis, while sitting upright.
Case 1. Vascular cervical vertigo.
An otherwise healthy man was involved in a severe auto accident. On awakening, he was dizzy and he developed severe neck pain over ensuing days. Evaluation in the hospital revealed a BPPV type positional nystagmus, which responded to physical treatment. He had persistent unsteadiness. After discharge from the hospital, on shaking his head forcefully to shake off some raindrops, he suddenly lost vision in one half of his visual field. Vision returned, but at that point a diagnosis of vertebral basilar compression was made. He continues to have unusual visual symptoms, attributed to poor circulation to the back of the brain. Comment: This is an extremely rare situation.
Case 2. Vascular cervical vertigo.
An otherwise healthy woman complained of positional vertigo elicited by turning the head to the left. On positional testing, after roughly a 20 second latency, she developed an extremely powerful right-beating nystagmus, which persisted as long as the head was turned to the left, and was accompanied by additional symptoms such as ear fullness, and at one point, a spot in the vision. She did not get nauseated. When she was tested upright with the head turned to the left side, after 20 seconds she developed a powerful right-beating nystagmus (see below). CT-angiography only revealed an aberrant right subclavian. Nevertheless, we attribute her symptoms to vascular compression in as much as no other mechanism would be likely to cause a 20 second delayed nystagmus. Comment: This is an extremely rare situation.
Case 3. Vascular cervical vertigo (vertebro-basilar insufficiency)
An 88-year-old white male with diabetes complains of dizziness and imbalance for the last six months. In particular, he complains of spinning, lightheadedness, trouble with his hearing, and attacks once or twice per day. Standing up, rapid head movements, walking in a dark room, not eating, exercise, and coughing or sneezing can trigger symptoms. A brain MRI scan, showed tiny chronic infarctions involving the right side of the thalamus and the left cerebellar hemisphere. Hemoglobin A1c was 8.6.
Under video Frenzel's goggles, there is no spontaneous nystagmus but with the vertebral artery test, when his head is turned to the right and left there for about 10-15 seconds, he reproducibly develops a weak down-beating nystagmus.
Movie of positive Vertebral artery Test (10 meg download)
Case 4. Herniated disk associated with cervical vertigo.
Another otherwise healthy man was involved in an auto accident. He was wearing a seat belt, and while his head rotated forward and backward, there was no substantial trauma to the head. In other words, it is difficult to attribute symptoms to a concussion. A disabling vertigo ensued, characterized by nausea and motion intolerance. Physical examination revealed a weak horizontal nystagmus that could be elicited by turning the head to one side (positive "vertebral artery test"). MRI of the neck revealed a C5-C6 disk herniation, abutting the thecal sac. Comment: Nystagmus in this case does not begin immediately but starts after about 10 seconds of head turning. This is the most common association between neck injury and dizziness. Our hypothesis is that in these situations there is disturbance of ascending input in the cervical cord going to the vestibular nucleus.
Movie of cervical vertigo (30 meg download)
Case 5. Cervical afferent disturbance associated with cervical vertigo.
An otherwise healthy 32 year old woman developed neck pain, dizziness, and inability to drive due to visual sensitivity. Audiometry was normal. An MRI/A showed a small vertebral on the left but a CT-angiogram was completely normal. MRI of the neck showed some mild disk disease. On examination there was significant tenderness to the posterior neck muscles. Positional testing revealed a weak direction changing positional nystagmus, which did not reverse with head prone. Comment: the nystagmus in this case as well as other similar ones was weak and came on immediately with positioning. It seems likely that here there was changing sensory input from neck muscles. Another way to organize this data would be to attribute symptoms to cervicogenic migraine.
Case 6. Mysterious case of vertigo attributed to the neck (Heidenreich et al, 2008).
These authors report a swimmer with dizziness elicited by swimming. There was a 11 deg/sec nystagmus (left/upward) during positional testing supine, and also a 5 deg/sec leftward nystagmus with sustained neck rotation to the right, with none seen with neck rotation to the left. Here, it is difficult to see why there should be upbeating nystagmus with head supine. This would make us consider migraine associated vertigo, as nystagmus that is gravity sensitive, would not reasonably be from the neck. On the other hand, the upright testing results -- which might be reasonably called neck nystagmus, might reasonably be attributed to the neck. It is difficult to know here whether or not the eyes were centered during the testing, due to a lack of traces. Usually this type of nystagmus might be called "cervical nystagmus".