Differential Diagnosis

The short version

Several conditions can look like cervicogenic dizziness. The most important to recognise are:

• BPPV — loose crystals in the inner ear. Brief spinning when the head changes position. Most common cause of position-triggered dizziness.
• Vestibular neuritis — sudden viral infection of the balance nerve. Days of continuous spinning that gradually settles.
• Vestibular migraine — episodes of dizziness in someone with a migraine history. Often comes with headache, sound or light sensitivity, and — the trap — neck pain.
• Ménière's disease — attacks of vertigo with a full feeling in one ear, hearing fluctuation, and tinnitus.
• PPPD — chronic daily unsteadiness, worse standing or in busy visual environments. Often follows a vestibular event.
• Vestibular schwannoma — tumour on the balance nerve. Asymmetric hearing loss with imbalance.
• Rotational vertebral artery syndrome — rare mechanical compression of the artery on neck rotation. Brainstem symptoms.
• Posterior-circulation stroke — rarest of all in this group but the most dangerous. Acute persistent dizziness with new neurological signs.

The tool below lets you toggle the features you've observed and shows how the differential shifts. The point is not to give you a diagnosis from a checkbox list — it is to make visible how each diagnosis depends on a specific feature profile, so the structure of the differential becomes intuitive.

Why the differential is the module

Cervicogenic dizziness, in current usage, is what remains after eight other conditions have been excluded. The Bárány Society made the point sharply in their 2022 position statement: the evidence for a unique mechanistic link between cervical pathology and an illusory sensation of self-motion remains lacking, which means the diagnostic label is only as durable as the rigour with which alternatives have been ruled out.²² This module is the rigour.

The eight competitors below are presented with their consensus criteria, the features that distinguish them, and where they tend to overlap with cervicogenic dizziness. After the prose walk-through, the engine and comparison grid let you stress-test the differential against any particular patient.

BPPV — Benign Paroxysmal Positional Vertigo

The Bárány consensus criteria require recurrent brief (seconds-long) vertigo episodes triggered by head-position changes, with characteristic positional nystagmus on Dix-Hallpike (posterior canal variant) or supine head-roll (horizontal canal variant).⁴¹

• Overlap with cervicogenic dizziness. Both are position-triggered. Patients describe both as "it happens when I move my head."
• What distinguishes them. BPPV episodes are seconds long with a latency before symptom onset; cervicogenic symptoms are sustained while the neck is held in the provocative position and resolve more slowly. The Dix-Hallpike and supine roll are decisive when positive — and they should always be performed first, before any cervical provocation.
• The trap. A horizontal-canal BPPV provoked by trunk rotation can produce a falsely positive cervical-torsion test if the head-on-trunk relationship is not adequately controlled. This is the most-common-diagnostic-error finding in the cervical dizziness literature.

Vestibular Neuritis

The 2022 Strupp et al criteria define acute unilateral vestibulopathy as acute or subacute onset of sustained spinning or non-spinning vertigo lasting at least 24 hours, with clear peripheral vestibular signs — spontaneous horizontal-torsional nystagmus, ipsilesional impairment of the vestibulo-ocular reflex demonstrated by head-impulse testing or caloric testing.⁴⁰

• Overlap with cervicogenic dizziness. Limited. But patients in the recovery phase, weeks after an acute episode, can present with neck stiffness from compensatory posturing — and then the picture starts to look mixed.
• What distinguishes them. The vHIT is the workhorse. Abnormal horizontal-canal VOR gain on one side, with corrective saccades, is incompatible with primary cervicogenic dizziness.

Vestibular Migraine — the most-likely missed diagnosis

The Lempert et al criteria define vestibular migraine as at least five episodes of moderate-to-severe vestibular symptoms lasting 5 minutes to 72 hours in a patient with a current or previous history of migraine, with at least half of the episodes accompanied by migrainous features.³⁷ The 2022 update is a literature-update consensus document of the Bárány Society and the International Headache Society.

The Bárány Society's 2022 cervical-dizziness position statement included an explicit warning: "Migraine, including vestibular migraine, is by far the commonest cause for the combination of neck pain and vestibular symptoms."²² This is the single most consequential differential point in the entire atlas.

• Overlap with cervicogenic dizziness. Massive. Migraine attacks frequently involve neck pain — sometimes as the leading feature. The patient correctly identifies that their neck is sore and their head is spinning; the clinician incorrectly attributes the second to the first.
• What distinguishes them. Personal or family history of migraine, episodic rather than position-triggered pattern, photophobia or phonophobia with the episodes, response to migraine-specific treatment.
• The clinical rule. In any patient where cervicogenic dizziness is being considered, screen for vestibular migraine first. If criteria for vestibular migraine are met, that diagnosis takes precedence — and may be the entire explanation, with the cervical features either coincidental or part of the migraine itself.

Ménière's Disease

The 2015 López-Escámez consensus criteria define definite Ménière's as two or more spontaneous episodes of vertigo lasting 20 minutes to 12 hours, audiometrically documented low- to medium-frequency sensorineural hearing loss in the affected ear on at least one occasion, fluctuating aural symptoms (hearing, tinnitus or fullness) in the affected ear, and exclusion of other vestibular diagnoses.³⁹

• Overlap with cervicogenic dizziness. Modest. But chronic Ménière's patients sometimes develop secondary neck stiffness from gait-strategy adaptations.
• What distinguishes them. The audiovestibular triad — fluctuating hearing, tinnitus, aural fullness in the affected ear. Audiometry is decisive.

PPPD — Persistent Postural-Perceptual Dizziness

The 2017 Staab criteria require one or more symptoms of dizziness, unsteadiness, or non-spinning vertigo present on most days for three months or more, exacerbated by upright posture, active or passive motion, and exposure to moving or complex visual stimuli.³⁸ PPPD is frequently precipitated by another vestibular event (BPPV, vestibular neuritis, vestibular migraine) and persists after the original disturbance has resolved.

• Overlap with cervicogenic dizziness. Substantial — and underappreciated. Chronic cervicogenic patients who have reweighted toward visual dependence (Module 3) develop a clinical picture that overlaps PPPD almost completely. The two diagnoses may co-exist.
• What distinguishes them. PPPD is non-spinning, daily, and exacerbated by upright posture and visual environments rather than by specific neck positions. Where cervicogenic dizziness improves with cervical-directed treatment, PPPD typically does not.

Vestibular Schwannoma

A slow-growing tumour of the vestibulocochlear nerve. The characteristic presentation is asymmetric high-frequency sensorineural hearing loss with unilateral tinnitus and progressive imbalance. Vestibular schwannoma is the diagnosis for which the cost of missing it is most disproportionate to its rarity — the screening test (MRI brain with IAC protocol) is widely available and the symptom set is recognisable.

• Overlap with cervicogenic dizziness. Limited but real — the imbalance can present before the hearing loss becomes obvious.
• What distinguishes them. Any asymmetric audiovestibular feature mandates audiometry and MRI brain with IAC protocol. Do not skip this step in a patient with chronic imbalance who happens to have neck pain.

Rotational Vertebral Artery Syndrome (RVAS)

Mechanical compression of the dominant vertebral artery during sustained head rotation, producing transient vertebrobasilar insufficiency.²⁴ Rare but consequential — it is the one cause of position-evoked dizziness on this differential that can produce a brainstem stroke.

• Overlap with cervicogenic dizziness. The biggest of any of these — both are triggered by neck position.
• What distinguishes them. Brainstem features during the provoked episode — diplopia, dysarthria, drop attacks, transient hemisensory or hemimotor signs. Cervicogenic dizziness produces proprioceptive symptoms, not brainstem ones. Dynamic Doppler confirms the suspicion (Module 6).

Posterior-Circulation Stroke or TIA

The most dangerous diagnosis on the list and the rarest in ambulatory cervical-dizziness practice. The signature is acute persistent vertigo, often with new neurological signs, and a HINTS examination consistent with central pathology — a normal head impulse test in the setting of spontaneous continuous spinning is paradoxically the strongest predictor of a central lesion.³²

• Overlap with cervicogenic dizziness. Almost none in chronic patients. The relevant scenario is the acute presentation, where the question is not "is this cervicogenic" but "is this stroke."
• What distinguishes them. Acute persistent vertigo with vascular risk factors and central oculomotor signs warrants urgent neurological evaluation and imaging.

The interactive engine

The engine below scores each diagnosis against the features you select. Each diagnosis has a feature profile — features that support the diagnosis (positive weights) and features that argue against it (negative weights). The weights are inspectable in lib/ddx.ts and the math is deliberately simple: the rawScore is the sum of weights of features the user has selected, and the fit percentage normalises against the maximum possible positive score.

The intent is pedagogical rather than diagnostic:

• Each feature contributes visibly to each diagnosis's score, so the structure of the differential is exposed.
• The same feature can support one diagnosis and oppose another — e.g. "neck rotation triggered" supports RVAS but argues against vestibular neuritis.
• Ranking shifts are interpretable: when the patient gains a migraine history, vestibular migraine should rise — and it does. When central oculomotor signs are added, cervicogenic should fall — and it does.

Quick-scan comparison

Reasoning patterns at the bedside

The order of the workup is the order of the exclusion

A defensible cervicogenic diagnosis follows a specific investigative sequence, and the sequence matters because the earlier steps remove the most-common alternatives:

1. Positional testing first — Dix-Hallpike and supine roll, every time, before any cervical provocation. BPPV is the most common cause of position-triggered dizziness and the easiest to miss-and-mis-label.
2. Screen for vestibular migraine — personal and family migraine history, episode duration, light/sound sensitivity, headache association. If criteria are met, treat as vestibular migraine and re-assess after a trial of prophylaxis; the cervical findings may melt away with the migraine.
3. vHIT, VNG, calorics — to rule out peripheral and central vestibular pathology (Module 5). A clean workup does not establish cervicogenic dizziness but is a precondition for the label.
4. Audiometry — asymmetric sensorineural hearing loss mandates MRI brain with IAC protocol regardless of other findings. The schwannoma catch is cheap and consequential.
5. Dynamic vascular imaging — only if rotation-triggered brainstem features are present (Module 6). Without those features, RVAS is vanishingly unlikely.
6. Cervical examination (Module 4) — SPNT, JPE, cervical torsion. These earn diagnostic weight only after the earlier steps are clean.

The four high-frequency mis-labels

Four diagnostic errors recur with high frequency in this literature; each deserves a specific guardrail:

• BPPV mis-labelled as cervicogenic. Guardrail — always perform Dix-Hallpike and supine roll first.
• Vestibular migraine mis-labelled as cervicogenic. Guardrail — explicit migraine screen in any patient where cervicogenic dizziness is being entertained, with low threshold for a prophylaxis trial.
• Schwannoma mis-labelled as anything. Guardrail — audiometry in every patient with chronic imbalance, MRI for any asymmetry.
• PPPD mis-labelled as cervicogenic, or vice versa. Guardrail — the two may co-exist; ask explicitly about symptom exacerbation by upright posture and busy visual environments. If those features dominate, PPPD is the primary diagnosis even if cervical findings are also present.

When more than one diagnosis is right

Co-existing diagnoses are common and clinically important. A patient may have:

• Vestibular migraine and cervicogenic features — treat the migraine first; reassess the cervical features after.
• BPPV and cervicogenic features — reposition the BPPV; reassess the cervical features when the positional vertigo has settled.
• Post-neuritis residual plus PPPD plus cervical reweighting — the chronic patient. This is the most complex management pathway and Module 8 develops it in detail.

The engine as a teaching scaffold

The interactive engine is built for trainees, not consultants — its purpose is to make the differential structure of cervical dizziness visible, not to replace clinical judgement. Several features deserve clinician-level interpretation:

• Weights are not probabilities. They are ordinal expert priors. A 3 means "criterion-level," a 1 means "supportive but not specific." Two diagnoses with the same fit percentage are not equally likely — they are equally fitting their respective feature profiles.
• Absent features are not zero-weighted. The engine considers only features the user has actively selected. A diagnosis with many criterion-level features that the user has not toggled will rank lower than its true likelihood — and this is intentional, because the engine must reflect what is known, not what is assumed.
• The top-call banner is provocative, not authoritative. It surfaces the ranking when at least one feature is selected. The clinician's job is to interrogate the ranking, not accept it.