TREATMENT OF CERVICAL VERTIGO (cervicogenic dizziness):

Timothy C. Hain, MD • Page last modified: January 16, 2023

See also: cervical vertigo (overview)• diagnosis•Treatment•Cases• Controversy•History•References

TREATMENT OF CERVICAL VERTIGO (cervicogenic dizziness):

What we do suggest doing for cervical vertigo:

For the usual person in whom cervical vertigo is a diagnosis of exclusion, and pain is prominent, physical therapy treatment is recommended, possibly combined with medication to relieve pain and reduce spasm.

• Physical therapy includes gentle mobilization, exercise, and instruction in proper posture and use of the neck (Karlberg et al, 1996). Some authors recommend trigger point injection or traction. The prognosis is good in that 75% of patients treated this way have improvement of symptoms. This may be simply due to waiting while the great healer - -passage of time -- kicks in.
  • Aggressive physical therapy in which vigorous "mobilization" is intended, often make cervical vertigo worse. It is difficult to see how physical therapy could increase sensation to the neck. However, it is easy to see how physical therapy could decrease pain from the neck.
  • We favor a type of physical therapist called a "manual therapist" for cervical vertigo. These individuals have more training with neck conditions. Manual therapy has been shown to help cervical vertigo (e.g. Lystad et al, 2011).   aaompt.org/directory/memberSearch.cfm provides a tool that can help in finding a manual therapist.
• Chiropractors often have competence with manual therapy. However, we are not sure how one would go about screening chiropractors, as our experience is that they have a very wide "range" of practice. We discourage patients with vertigo of any cause to undergo "snapping" of the neck, which is often within the chiropractic repertoire. We would also advise dizzy patients to be very wary of clinicians who use dubious explanations for common dizziness symptoms such as "cerebellar dysfunction", or suggesting that one should undergo adjustment of the "atlas".
• Medical management may include muscle relaxants such as tizanidine (Zanaflex), cyclobenzaprine (10 mg), and baclofen (Lioresal). Soma may also be useful. For pain, tramadol (Ultram) and non-steroidals are sometimes useful. Nonsteroidals are particularly useful when arthritis is present, or migraine is a mechanism.
• Antidepressants, may be used for chronic pain and the reactive depression that often accompanies it.(Borg-Stein et al, 2001).
• There can be an interaction between migraine (which can include vertigo) and neck pain, and for this reason, it is often useful to empirically try medication with migraine prophylactic medications. We particularly favor venlafaxine.
• Again for pain, cervical blocks of the facet joints or dorsal root are sometimes helpful.
• Botulinum toxin injections and similar drugs can reduce painful muscle spasm. Odderson (2020) reported "Chemodenervation was effective in treating cervical vertigo and is likely to have altered the cervical proprioceptive input by relaxing the overactive muscles and/or by decompression of cervical nerves. " This treatment is promising. This approach is very expensive because the neck muscles are large and considerable drug is needed !
• When all of the above fails, immobilization of the neck through a collar or surgery can be contemplated.

• Surgery -- anterior approach removal followed by a fusion for spinal stenosis (called ACDF)-- is rarely done but it often improves cervical vertigo. This should not be entered into lightly as most persons having this done experience chronic pain, spasms, and neck restriction. Improved surgical techniques for the cervical spine -- especially disk replacement -- seems likely to eventually offer better results for spinal stenosis. However, perhaps this will not result in better results for cervical vertigo- -the reason why fusions generally work for cervical vertigo may be due to their effect on restricting neck mobility. If this is the case, more sophisticated surgical procedures that are less invasive, and less restrictive, could also be less effective. For example, cervical foraminotomy for arm pain is reported as effective as ACDF(Broekema et al, 2023), but one would not expect it to restrict neck motion and perhaps might not help as much as an ACDF.
  • Hermansen et al (2019) reported that about 1/3 of persons who had neck fusions complain of dizziness 10 years later.
  • Ren et al (2014) reported improvement with "laser disk decompression", in an uncontrolled study.
• Prevention: protect your neck. Avoid more whiplash injuries. Drive an unusually safe vehicle -- such as a larger vehicle. Don't practice exercises that involve extreme head on neck movements.

What we suggest not doing:

Chiropractic treatment for cervical vertigo.

We generally think that chiropractic treatment is not a good idea for vertigo of any type, including cervical vertigo. We realize that this may not set well with the chiropractic community, but this is the author's opinion.

There are two reasons:

• 1). Chiropractic treatment is associated with stroke in young people (Rothwell et al). This is very likely due to compression of the vertebral arteries at the top of the spine (Mann, Refshauge, 2001).
• 2). There is no mechanism listed above in which chiropractic treatment is more likely to help than physical therapy.

Bizzare treatments such as lasers.

There are very bizarre treatments that have been reported for cervical vertigo, that we will mention briefly. In recent years, the general population has gotten the idea that lasers are good for nearly any medical problem. We have encountered, for example, situations where lasers to the external ear are suggested as treatment for tinnitus. This seems to us simple fraud. In a similar way, some have suggested that "laser acupuncture" is effective for cervical vertigo. This is implausible as lasers have no mechanism of manipulating the neck. The literature substantiates that laser acupuncture is ineffective for cervical vertigo (Aigner et al, 2004).

Zhu et al (2019) suggested "Cervical lamina block therapy could significantly shorten the clinical hospital stays of patients with cervical vertigo (P = 0.000) and improve vertebral artery flow (P < 0.05)". We think it is a bizzare idea that any type of block could do anything more than make a temporary change. It might be a helpful diagnostic test however.

PROGNOSIS of cervical vertigo.

Cervical vertigo is poorly defined, and due to this, no relevant studies exist of prognosis.  In the author's clinical practice, his impression is that cervical vertigo is a poor prognosis condition. The reason for this is that the musculoskeletal conditions that are associated with cervical vertigo  - neck stiffness, pain, disk disease and facet arthropathy, are also slow to resolve.  A second reason may be that the patients seen in the author's clinic usually have already had symptoms for many months.

With respect to the chronicity of whiplash injuries, Dufton et al (2012), recently found in a very large study that about 25% of persons after whiplash injury develop chronic symptoms. Another recent meta-analysis reported that between 14 and 42% of patients with WAD will develop chronic neck pain (Rodriquez, Barr et al. 2004). In the same study, it pointed out that roughly 75% of all persons with injury, had previous neck pain.

REFERENCES:

See also: cervical vertigo (overview)• diagnosis•Treatment•Cases• Controversy•History•References