Cases · Sympathetic loop dominant · trainee

The yoga teacher with autonomic-heavy episodes

A 44-year-old yoga teacher whose neck flare-ups bring nausea, palpitations, and pallor more than spinning.

Vignette

A 44-year-old yoga teacher presents with two years of episodic 'unwell' spells — but vertigo is not what dominates the picture. During an episode (3–5 per month) she feels a wave of nausea, palpitations, pallor, sweating, and lightheadedness, lasting 20–40 minutes. There is a low-grade swimming sensation rather than true vertigo. The episodes follow days when she has demonstrated head-down postures repeatedly in classes or has slept poorly with her neck cricked. She has chronic intermittent upper trapezius and posterior neck pain, mild ongoing anxiety, and a normal cardiology workup including 24-hour ECG.

Examination and workup

Cervical examination shows tender right C2/3 facet, restricted upper cervical extension, mildly positive cervical torsion test. JPE 5.1° on right rotation (just abnormal), SPNT difference 0.13. vHIT, VNG, calorics, audiometry, Dix-Hallpike all normal. Tilt-table testing previously normal. No central oculomotor signs.

Question

Which combination best addresses the dominant clinical picture?

AManual therapy plus cervical proprioceptive retraining, with short-course antiemetic cover for autonomic flare-ups and breathing/relaxation work
BRefer to cardiology for further investigation of the palpitations and lightheadedness
CFirst-generation antihistamine (e.g. promethazine) regularly for 6 weeks to manage the autonomic features
DDiagnostic re-evaluation for vestibular migraine given the autonomic prominence
EAnxiolytic therapy with a long-term benzodiazepine for the anxiety component

Select an option to reveal the answer.

Teaching point

The vestibulo-sympathetic loop (Module 3 Mechanism 2) explains why some cervicogenic-dizziness patients present with autonomic features that look louder than the dizziness itself. Treatment is the Route 1 backbone plus targeted Route 2 adjuncts. Avoid the cardiology workup spiral when the autonomic features cleanly track cervical triggers and the basic cardiac workup is unrevealing, and avoid stacked anticholinergic suppressants.

References

⁵ Yang L, Yang C, Pang X, Li D, Yang H, Zhang X, et al. (2022). Proprioceptive cervicogenic dizziness: a narrative review of pathogenesis, diagnosis, and treatment. Journal of Clinical Medicine, 11(21):6293. link
²⁵ Thompson-Harvey A, Hain TC (2019). Symptoms in cervical vertigo. Laryngoscope Investigative Otolaryngology, 4(1):109–115. link
⁸ Thunberg J, Hellström F, Sjölander P, Bergenheim M, Wenngren B, Johansson H (2001). Influences on the fusimotor-muscle spindle system from chemosensitive nerve endings in cervical facet joints in the cat. Pain, 91(1-2):15–22. link