Cervicogenic Dizziness — Print Edition

A single-document export of every clinically actionable reference in the atlas: BPPV manoeuvres, patient handouts, validated instruments (DHI & NDI), the 9 disease archetypes, the 48-term glossary, and the full reference list.

The module prose for each chapter remains on its own page — this is the consolidated bedside reference. Use the button below or Cmd/Ctrl+P to produce a printable A4 document.

1. BPPV manoeuvres

Dix-Hallpike manoeuvre diagnostic

Diagnostic test for posterior canal BPPV. Tests one side at a time; positive when characteristic upbeating-torsional nystagmus is provoked.

Indication. Any patient with brief positional vertigo, particularly triggered by lying down, looking up, or rolling over in bed. Always performed BEFORE any cervical provocation in the workup of dizziness with neck pain.

Patient sits upright. Patient is seated on the examination couch with their legs extended, so that when they lie back their head will be off the end of the couch (you support the head). Warn the patient that the manoeuvre may briefly provoke their symptoms.
Rotate head 45°. Turn the patient's head 45° toward the side being tested (affected ear). Keep the eyes open and focused straight ahead.
Lay supine, head extended 20°. Quickly but smoothly lay the patient supine, supporting the head so it hangs 20° below the horizontal, with the 45° rotation maintained. The affected ear is now down. (hold ≥ 30s)
Observe for nystagmus. Watch the patient's eyes for at least 30 seconds. Note any latency, direction, duration, and fatigability of nystagmus, and ask about subjective vertigo. (hold ≥ 30s)
Return to upright. Slowly bring the patient back to the seated upright position. Observe again — a brief reversal-direction nystagmus may occur.
Test the other side. Repeat steps 1–5 with the head turned to the opposite side. The side that reproduces symptoms and characteristic nystagmus is the affected side.

Expected finding. Positive for posterior canal BPPV when, after a 1–5 second latency, the patient develops upbeating-and-torsional nystagmus (top pole of eye beating toward the lower ear) lasting <60 seconds and fatiguing with repetition, accompanied by the patient's characteristic vertigo.

Cautions.

Cervical instability or recent cervical fracture — use modified side-lying technique instead.
Severe cervical osteoarthritis with limited extension — reduce extension to comfort, or use a half-Dix-Hallpike.
Carotid bruit or known severe vertebrobasilar disease — relative caution; sustained head rotation should be brief.
Acute cervical pain that the manoeuvre would worsen — defer until cervical irritability has settled, or use Side-Lying test.

Supine roll test (Pagnini-McClure) diagnostic

Diagnostic test for lateral / horizontal canal BPPV. Distinguishes geotropic from apogeotropic variants by the direction of provoked nystagmus.

Indication. Performed when the Dix-Hallpike is negative or atypical but positional vertigo persists, or when posterior canal repositioning has produced a 'canal conversion' to horizontal canal nystagmus.

Patient supine, head flexed 30°. Patient lies flat on the couch with the head supported in 30° of flexion (a pillow under the upper back works well). This brings the lateral semicircular canal into the vertical plane.
Roll head 90° to one side. Quickly roll the patient's head 90° to one side. Observe the eyes for at least 30 seconds, noting direction (toward earth = geotropic; toward ceiling = apogeotropic), duration, and intensity. (hold ≥ 30s)
Return to centre. Bring the head back to the neutral midline (still flexed 30°). Allow any residual nystagmus to settle. (hold ≥ 20s)
Roll 90° to the opposite side. Roll the head 90° to the opposite side and observe for 30 seconds. Compare intensity and duration with the first side. (hold ≥ 30s)

Expected finding. Geotropic horizontal nystagmus (beating toward the earth on both sides, more intense when the affected ear is down) indicates canalithiasis of the lateral canal — affected ear is the side with the more intense response. Apogeotropic nystagmus (beating toward the ceiling on both sides) suggests cupulolithiasis or a variant — affected ear is the side with the LESS intense response.

Cautions.

Same as Dix-Hallpike — cervical instability, severe cervical disease, or carotid pathology.

Epley canalith repositioning manoeuvre therapeutic

First-line treatment for posterior canal BPPV. Single-session success rate approximately 80%.

Indication. Confirmed posterior canal BPPV on Dix-Hallpike (characteristic upbeating-torsional nystagmus on the affected side).

Sit upright, head rotated 45° to affected side. Start as for Dix-Hallpike — patient seated, head turned 45° to the affected side.
Lay supine with head extended 20°, affected ear down. Move briskly into the Dix-Hallpike end position. Hold until the provoked nystagmus subsides or for at least 30 seconds, whichever is longer. (hold ≥ 30s)
Rotate head 90° to opposite side. Without sitting up, rotate the head 90° so it is now turned toward the unaffected side, head still hanging 20° below horizontal. Hold for ≥30 seconds. (hold ≥ 30s)
Roll body and head a further 90°. Have the patient roll onto the unaffected-side shoulder so they are lying on that side, with the head now turned to look toward the floor (135° from start). Hold for ≥30 seconds. (hold ≥ 30s)
Sit upright. Slowly bring the patient to a seated upright position. A brief sensation of disequilibrium is common.

Expected finding. Successful repositioning resolves the patient's symptoms and abolishes the Dix-Hallpike response when re-tested. Brief residual symptoms over 24–48 hours are normal. If symptoms persist or recur, repeat the manoeuvre — multiple sessions can be required.

After-care. The 2017 AAO clinical practice guideline makes a strong recommendation AGAINST post-procedure postural restrictions (e.g. avoiding lying flat, sleeping upright, no head-down positions). These restrictions do not improve outcomes and are uncomfortable. The patient may resume normal activities immediately.

Cautions.

Cervical instability or recent cervical fracture.
Severe cervical osteoarthritis — modify the angle or use the alternative Semont manoeuvre.
Recent retinal detachment surgery or severe glaucoma — discuss with ophthalmology before head-down manoeuvres.

Semont liberatory manoeuvre therapeutic

Alternative therapeutic manoeuvre for posterior canal BPPV. Uses rapid lateral position changes rather than head rotation. Similar efficacy to Epley in network meta-analysis.

Indication. Posterior canal BPPV — particularly useful when cervical extension is limited or painful, since the Semont avoids the head-hanging position required by the Epley.

Sit on the edge of the couch, head rotated 45° to unaffected side. Patient sits on the edge of the couch facing forward. Turn the head 45° toward the UNAFFECTED side (note: opposite to Epley start). Maintain this head rotation throughout the procedure.
Briskly drop to affected side. Quickly tilt the patient to lie on the AFFECTED side (the side with positive Dix-Hallpike). The head remains rotated 45° toward the unaffected side, so the affected ear is now toward the ceiling and the nose toward the floor. Hold for ≥1 minute or until nystagmus settles. (hold ≥ 90s)
Briskly swing through to unaffected side. Rapidly (within ~1.5 seconds) swing the patient through the upright position over to lie on the UNAFFECTED side, MAINTAINING the head rotation so the nose now points to the floor. Hold for ≥1 minute. (hold ≥ 90s)
Return to seated upright. Slowly bring the patient back to the seated upright position. Allow any disequilibrium to settle.

Expected finding. Successful liberation resolves the patient's symptoms. As with the Epley, brief residual symptoms over 24–48 hours are normal.

After-care. Per the 2017 AAO guideline, no post-procedure restrictions are recommended.

Cautions.

The swing-through is brisk — patient should be warned and pre-positioned safely.
Cervical pain that limits sustained head rotation — counselling and careful technique required.
Frail or unsteady patients — perform with an assistant or skip in favour of the Epley.

Lempert barbecue roll manoeuvre therapeutic

First-line therapeutic manoeuvre for geotropic lateral canal BPPV. Rotates the patient 270° around the long axis to flush otoconia back into the utricle.

Indication. Geotropic lateral / horizontal canal BPPV on supine roll test. Direction of rotation: always TOWARD the unaffected side, in 90° increments.

Supine, head flexed 30°, affected ear down. Start with the patient supine, head flexed 30°, and the head turned 90° so the affected ear is down. Hold ≥30 seconds. (hold ≥ 30s)
Rotate 90° toward unaffected side — face up. Roll the patient through 90° toward the unaffected side so they are supine with the head in midline (still flexed 30°). Hold ≥30 seconds. (hold ≥ 30s)
Rotate a further 90° — unaffected ear down. Continue rolling toward the unaffected side so the patient is now lying on the unaffected side, with the unaffected ear down. Hold ≥30 seconds. (hold ≥ 30s)
Rotate a further 90° — face down. Continue rolling so the patient is now prone with the nose toward the floor (head still 30° flexed). Hold ≥30 seconds. (hold ≥ 30s)
Sit up via the unaffected side. Have the patient slowly come to a seated position by rolling onto their hands and knees and then sitting up. A brief sensation of motion is normal.

Expected finding. Successful repositioning abolishes the supine-roll nystagmus and resolves the patient's symptoms. Conversion to a different canal occasionally occurs — re-examine if symptoms persist.

After-care. No specific post-procedure restrictions. Patients should be advised that brief residual disequilibrium over 24–48 hours is normal.

Cautions.

The full 360° rotation is physically demanding — frail or obese patients may not tolerate it. Consider Gufoni as an alternative.
Apogeotropic variant requires a different manoeuvre (Gufoni or modified Lempert with initial nose-down conversion).
Standard cervical-spine cautions as for the other manoeuvres.

2. Patient handouts

Plain-language A4 handouts mapped to the four mechanism routes from Module 8. Print individually from /tools/handouts/<id>; the canonical content is reproduced here.

Dizziness from neck signals — your information sheet

When the muscles and joints of your neck are sending mixed messages to your balance system

What's going on

Your neck plays an important part in balance. Tiny sensors in the joints and deep muscles of the upper neck constantly send information to the brain about which way your head is positioned. The balance organs of the inner ear and the visual system add their own information, and the brain combines all three to keep you upright and to keep your vision steady.

When the neck sensors send unreliable information — usually because of pain, stiffness, or restricted movement — the brain receives a 'mixed message.' The eyes and inner ears are reporting one position, but the neck is reporting something different. The brain registers this mismatch as a foggy unsteadiness, fullness in the head, or a sense that the world is not quite still.

The good news: this kind of dizziness responds well to treatment of the underlying neck problem. As the neck moves more freely and the deep muscles re-learn their job, the dizziness fades. Most people feel meaningful improvement within 6–12 weeks of structured treatment.

What helps

Manual therapy and gentle mobilisation of the stiff upper-neck joints by a trained physiotherapist or osteopath.
Specific exercises that retrain the deep neck muscles and the sense of head position — your therapist will teach you these.
Gentle pacing of activities that tend to flare your symptoms. You don't need to avoid them entirely — just build tolerance gradually.
Heat or warmth on the neck before exercises can help reduce stiffness.
Short courses of simple painkillers (paracetamol or anti-inflammatories) when pain is high — pain itself feeds the disturbance.
Adjusting your work setup: monitor at eye level, frequent breaks, good seating, hourly head and neck stretches.

What to avoid

Long-term use of soft cervical collars. They feel comforting but actually make the underlying problem worse over time.
Long-term anti-dizziness drugs (cinnarizine, prochlorperazine, betahistine, meclizine). These can blunt your body's natural recovery process.
Holding your head completely still for fear of triggering symptoms. Gentle controlled movement is part of the recovery.
Repeated imaging (X-rays, MRI) chasing a structural cause. The change in this condition is in how the sensors function, not in any single structure that scans can show.

When to seek further help

Symptoms get clearly worse instead of better despite treatment over 4–6 weeks.
You develop new symptoms: double vision, slurred speech, weakness in arm or leg, numbness, drop attacks, or hearing loss.
You experience true spinning vertigo that lasts more than a few seconds (not the fogginess of your usual symptoms).
You develop severe headaches that are different from your usual pattern.

Dizziness with autonomic symptoms — your information sheet

When neck-related dizziness brings nausea, palpitations, or feeling unwell more than spinning

What's going on

Some people whose dizziness comes from the neck experience the body's 'fight or flight' system being switched on alongside the dizziness. Their main complaint is not spinning but a wave of feeling unwell — nausea, pallor, sweating, palpitations, lightheadedness — that comes on when the neck flares.

This happens because the balance pathways in the brainstem are closely connected to the autonomic nervous system, which controls things like nausea and heart rate. When the neck-derived dizziness signal arrives, it can trigger these autonomic responses, particularly in people who run a bit anxious anyway.

Treating the neck problem usually settles the autonomic symptoms in parallel. Targeted help for the nausea and breathing during flare-ups makes the daily experience more tolerable while the underlying mechanism resolves.

What helps

Treatment of the underlying neck condition (see proprioceptive handout) — this is the foundation.
Diaphragmatic breathing or relaxation exercises practised daily, particularly during a flare-up. Slow nose-in, longer mouth-out breathing turns down the body's stress response.
An antiemetic (anti-sickness) prescribed for brief use during flares — your doctor may suggest ondansetron or metoclopramide.
Good hydration and regular meals — being dehydrated or hungry makes the symptoms worse.
Address anxiety if it's a contributor — talking therapies, mindfulness, and sometimes medication can quieten the loop.
Gentle aerobic exercise (walking, cycling, swimming) on the days you feel well — over time this calms the autonomic system.

What to avoid

Stacking multiple anti-dizziness drugs at once — meclizine plus betahistine plus a benzodiazepine is a recipe for side effects without targeting the problem.
Long-term benzodiazepines (diazepam, lorazepam). They blunt recovery and risk dependence.
Cardiology spiral if your initial cardiac workup is normal — repeated investigations rarely find a different answer when the symptoms cleanly track neck triggers.
Self-blame for the anxiety component. It's part of the picture, not a sign that the dizziness is 'all in your head.'

When to seek further help

Chest pain or severe breathlessness with episodes (different from the lightheadedness).
Fainting (full loss of consciousness) rather than just feeling like you might faint.
Symptoms suddenly very different in character or much worse than usual.
You feel unable to cope with the symptoms — there is help available.

Rotational artery dizziness — your information sheet

When sustained head turning briefly reduces blood flow to the back of the brain

What's going on

Two blood vessels — the vertebral arteries — run up the back of the neck and supply blood to the brainstem. In a small number of people, one of these arteries can be briefly pinched when the head is turned to a particular side for several seconds. This can produce a sudden 'unwell' feeling, brief double vision, or a sense of being about to fall, which clears as soon as the head returns to the middle.

This is uncommon but important to recognise because it is treatable — and because it is the one form of neck-related dizziness that, untreated, can occasionally cause a stroke. The treatment plan focuses on avoiding the position that triggers your symptoms, controlling vascular risk factors, and in some cases surgical decompression.

Most people who follow the plan do well. The key is treating this condition specifically and not mixing it up with the gentler manual treatments that suit other forms of neck dizziness.

What helps

Knowing your trigger position and avoiding sustained head turns into it. If your trigger is right rotation, get into the habit of turning your whole body to look right instead of just your head.
Reversing in the car using mirrors and the reversing camera — not the over-shoulder turn.
Tight blood-pressure control. Targets agreed with your GP.
If you smoke — stopping. Smoking damages the blood vessel walls and makes the condition worse.
Cholesterol-lowering medication if your levels are raised — your GP will advise.
Aspirin or a similar anti-platelet medication if your doctor has prescribed one.
Follow-up vascular imaging as advised — to monitor the artery.

What to avoid

Forceful neck manipulation ('clicking' or 'cracking' of the neck) — strictly avoid. This can be dangerous in your condition.
Yoga poses, exercises, or stretches that involve sustained head turning. Discuss with your instructor.
Habituation exercises (repeated provocation to 'desensitise' to symptoms) — appropriate for some kinds of dizziness, but not yours.
Holding the head in your trigger position for any prolonged time (e.g. painting overhead, hairdresser's basin, prolonged shoulder-check posture).

When to seek further help

URGENT — phone your local emergency number (e.g. 999/112/911) if symptoms last more than a few minutes after returning the head to neutral, or if you develop weakness, slurred speech, drooping face, or sudden severe headache.
Worsening of your usual pattern — symptoms triggered at smaller angles, more frequent, lasting longer.
New symptoms appearing between episodes (continuous unsteadiness, vision changes, memory problems).
A fall during an episode, even if you recover quickly.

Long-standing dizziness with visual sensitivity — your information sheet

When dizziness has become a learned pattern that needs gradual retraining

What's going on

When dizziness has been around for several months — sometimes after a specific trigger like a whiplash injury or an episode of vertigo, sometimes without an obvious cause — the brain can start to depend more heavily on visual information and start to expect dizziness in particular situations. This is a learned pattern, not damage. It is reversible, but the route back is different from the route used in the first few months.

You'll notice your symptoms are worse in busy visual environments — supermarkets, crowds, traffic, scrolling screens. You may feel better sitting in a quiet office. You may have started avoiding things and noticing your world shrinking. None of this means the original problem is getting worse; it means the brain has reweighted toward visual cues and is over-relying on them.

The treatment is gradual, structured retraining — exposing yourself to the situations you've been avoiding, in small steps, with support. It's slower than the first months of recovery, but it works. Improvement is usually measured in months rather than weeks, and there can be ups and downs along the way.

What helps

Vestibular rehabilitation guided by a physiotherapist who specialises in this — they will design a programme of head and eye exercises, balance work, and graded exposure to busy environments.
Returning to normal activities in a planned way — short walks in the supermarket aisle, time on a screen, time in crowds — building tolerance back up.
Treating the avoidance and worry. Some people benefit from cognitive-behavioural therapy or a course of an antidepressant (typically an SSRI) — these are evidence-based options for this kind of condition.
Regular aerobic exercise. Walking, cycling, swimming — at a level that gets you breathing harder for 20–30 minutes most days. This calms the central nervous system.
Good sleep and stress management. Both have a big effect on this condition.
Continuing any neck-directed exercises your physiotherapist has given you, as part of the broader programme.

What to avoid

Repeated imaging chasing a cause that the scans can't show. The change is in how the brain is using sensory information, not in any structural problem that imaging can capture.
Long-term anti-dizziness drugs. They prevent the very retraining the brain needs to do.
Withdrawing further from busy environments — every avoidance reinforces the pattern.
Comparing your timeline to other people's. This recovery is gradual and individual.
Treating yourself as fragile. Active engagement with structured rehabilitation works better than rest.

When to seek further help

Sudden new symptoms unlike your usual pattern — true spinning lasting hours, hearing changes, neurological symptoms.
A clear flare in cervical pain accompanied by worsening dizziness — may suggest a return of mechanical contribution.
Low mood or anxiety that is interfering with your ability to engage with treatment.
No progress at all over a 3–4 month period of structured rehabilitation.

3. Dizziness Handicap Inventory (DHI) — Jacobson & Newman 1990

25 items. Scoring: yes = 4 points, sometimes = 2, no = 0. Total 0–100. Bands: 0–30 mild, 31–60 moderate, 61–100 severe. MCID ≈ 18 points.

#	Subscale	Item
`P1`	physical	Does looking up increase your problem?
`P4`	physical	Does walking down the aisle of a supermarket increase your problem?
`P8`	physical	Does performing more ambitious activities (e.g. sports, dancing, household chores such as sweeping or putting dishes away) increase your problem?
`P11`	physical	Do quick movements of your head increase your problem?
`P13`	physical	Does turning over in bed increase your problem?
`P17`	physical	Does walking down a sidewalk increase your problem?
`P25`	physical	Does bending over increase your problem?
`E2`	emotional	Because of your problem, do you feel frustrated?
`E9`	emotional	Because of your problem, are you afraid to leave your home without having someone accompany you?
`E10`	emotional	Because of your problem, have you been embarrassed in front of others?
`E15`	emotional	Because of your problem, are you afraid people may think you are intoxicated?
`E18`	emotional	Because of your problem, is it difficult for you to concentrate?
`E20`	emotional	Because of your problem, are you afraid to stay home alone?
`E21`	emotional	Because of your problem, do you feel handicapped?
`E22`	emotional	Has your problem placed stress on your relationships with members of your family or friends?
`E23`	emotional	Because of your problem, are you depressed?
`F3`	functional	Because of your problem, do you restrict your travel for business or recreation?
`F5`	functional	Because of your problem, do you have difficulty getting into or out of bed?
`F6`	functional	Does your problem significantly restrict your participation in social activities, such as going out to dinner, the cinema, dancing, or to parties?
`F7`	functional	Because of your problem, do you have difficulty reading?
`F12`	functional	Because of your problem, do you avoid heights?
`F14`	functional	Because of your problem, is it difficult for you to do strenuous housework or yardwork?
`F16`	functional	Because of your problem, is it difficult for you to go for a walk by yourself?
`F19`	functional	Because of your problem, is it difficult for you to walk around your house in the dark?
`F24`	functional	Does your problem interfere with your job or household responsibilities?

4. Neck Disability Index (NDI) — Vernon & Mior 1991

10 sections, each scored 0–5 by picking the single statement that best describes the patient. Raw total 0–50 (or 0–100% if doubled). Bands: 0–4 none, 5–14 mild, 15–24 moderate, 25–34 severe, ≥35 complete. MCID ≈ 5 points.

1. Pain intensity

I have no pain at the moment.
The pain is very mild at the moment.
The pain is moderate at the moment.
The pain is fairly severe at the moment.
The pain is very severe at the moment.
The pain is the worst imaginable at the moment.

2. Personal care (washing, dressing, etc.)

I can look after myself normally without causing extra pain.
I can look after myself normally but it causes extra pain.
It is painful to look after myself and I am slow and careful.
I need some help but manage most of my personal care.
I need help every day in most aspects of self care.
I do not get dressed, I wash with difficulty and stay in bed.

3. Lifting

I can lift heavy weights without extra pain.
I can lift heavy weights but it gives extra pain.
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned.
Pain prevents me from lifting heavy weights, but I can manage light to medium weights if conveniently positioned.
I can lift very light weights.
I cannot lift or carry anything at all.

4. Reading

I can read as much as I want with no neck pain.
I can read as much as I want with slight neck pain.
I can read as much as I want with moderate neck pain.
I cannot read as much as I want because of moderate neck pain.
I can hardly read at all because of severe neck pain.
I cannot read at all.

5. Headaches

I have no headaches at all.
I have slight headaches that come infrequently.
I have moderate headaches that come infrequently.
I have moderate headaches that come frequently.
I have severe headaches that come frequently.
I have headaches almost all the time.

6. Concentration

I can concentrate fully when I want to with no difficulty.
I can concentrate fully when I want to with slight difficulty.
I have a fair degree of difficulty concentrating when I want to.
I have a lot of difficulty concentrating when I want to.
I have a great deal of difficulty concentrating when I want to.
I cannot concentrate at all.

7. Work

I can do as much work as I want.
I can only do my usual work but no more.
I can do most of my usual work but no more.
I cannot do my usual work.
I can hardly do any work at all.
I cannot do any work at all.

8. Driving

I can drive my car without any neck pain.
I can drive my car as long as I want with slight neck pain.
I can drive my car as long as I want with moderate neck pain.
I cannot drive my car as long as I want because of moderate neck pain.
I can hardly drive at all because of severe neck pain.
I cannot drive my car at all.

9. Sleeping

I have no trouble sleeping.
My sleep is slightly disturbed (less than 1 hour sleepless).
My sleep is mildly disturbed (1–2 hours sleepless).
My sleep is moderately disturbed (2–3 hours sleepless).
My sleep is greatly disturbed (3–5 hours sleepless).
My sleep is completely disturbed (5–7 hours sleepless).

10. Recreation

I am able to engage in all my recreational activities with no neck pain.
I am able to engage in all my recreational activities with some neck pain.
I am able to engage in most but not all my recreational activities because of neck pain.
I am able to engage in a few of my recreational activities because of neck pain.
I can hardly do any recreational activities because of neck pain.
I cannot do any recreational activities at all.

5. Disease archetypes

Nine clinical archetypes used by the pattern recognition trainer. For each, prominent (P) findings are those with archetype probability ≥ 0.7; variable (V) are 0.3–0.7; uncommon are absent.

Archetype	Cervical trigger	Visual dependence	Episodic discrete attacks	Migraine features	Positional spinning	Autonomic prominence	Brainstem features
Proprioceptive cervicogenic (Route 1)	P	V	—	—	—	—	—
Vestibulo-sympathetic loop (Route 2)	P	—	V	—	—	P	—
Rotational vertebral artery syndrome (Route 3, 'Bow Hunter')	P	—	P	—	—	—	P
Central reweighting / chronic (Route 4)	V	P	—	—	—	V	—
Vestibular migraine	V	V	P	P	—	V	—
Posterior canal BPPV	—	—	P	—	P	V	—
Lateral canal BPPV	—	—	P	—	P	V	—
PPPD (Persistent postural-perceptual dizziness)	—	P	—	—	—	V	—
Vestibular neuritis (acute peripheral)	—	V	—	—	—	P	—

Teaching summaries

Proprioceptive cervicogenic (Route 1)

Disturbed cervical proprioception is the dominant mechanism — usually after whiplash or chronic neck stiffness. Symptoms track the neck.

Vestibulo-sympathetic loop (Route 2)

Cervical input drives autonomic centres; the patient experiences nausea and palpitations more than spinning. Treatment of the neck plus autonomic settling helps in parallel.

Rotational vertebral artery syndrome (Route 3, 'Bow Hunter')

Sustained head rotation mechanically compresses the dominant vertebral artery, producing transient brainstem features. Avoid manipulation. Investigate vascular cause.

Central reweighting / chronic (Route 4)

After months of altered cervical input, the brain has reweighted toward vision. Cervical findings have often improved; the dizziness has not. Requires retraining, not more manual therapy.

Vestibular migraine

Discrete vestibular attacks with migrainous accompaniments. Premonitory neck stiffness is a recognised feature. The most commonly missed alternative to cervicogenic dizziness.

Posterior canal BPPV

Brief positional vertigo with upbeating-torsional nystagmus on Dix-Hallpike. Responds to Epley repositioning. The most common cause of vertigo overall.

Lateral canal BPPV

Direction-changing horizontal nystagmus on supine roll testing. Geotropic = canalithiasis; apogeotropic = cupulolithiasis. Lempert roll for geotropic; Gufoni for apogeotropic.

PPPD (Persistent postural-perceptual dizziness)

Persistent (≥3 months) non-vertiginous dizziness/unsteadiness made worse by upright posture, motion, and busy visual environments. Often follows an acute vestibular event. Overlaps with central reweighting but is a formal diagnostic entity.

Vestibular neuritis (acute peripheral)

Acute prolonged spontaneous vertigo with characteristic HINTS pattern (positive head impulse to affected side, unidirectional horizontal nystagmus, no skew). No hearing loss. Symptoms gradually settle over weeks.

6. Glossary

48 terms across 6 categories. Aliases shown in parentheses.

Apogeotropic nystagmus (ceiling-bound nystagmus): Nystagmus beating toward the upper ear (toward the ceiling) on supine roll testing. In lateral canal BPPV, apogeotropic nystagmus suggests cupulolithiasis or a variant. The affected ear is the side where the response is LESS intense (reverse of geotropic).
Asymmetric hearing loss (AHL): A side-to-side audiometric difference suggesting a retro-cochlear lesion. The classical screening criterion is >15 dB asymmetry at 3 or more contiguous frequencies. In a dizzy patient, asymmetric hearing loss raises suspicion of vestibular schwannoma and warrants MRI with IAM protocol.
Benign Paroxysmal Positional Vertigo (BPPV, positional vertigo): Brief positional vertigo caused by free-floating otoconia (canalithiasis) or otoconia adherent to a cupula (cupulolithiasis) in a semicircular canal. The most common cause of vertigo overall. Posterior canal BPPV is most common, but lateral canal BPPV exists and requires different treatment.
Brainstem symptoms (5 Ds, posterior circulation symptoms): Symptoms localising to the brainstem or posterior circulation: dizziness (with other features), diplopia, dysarthria, dysphagia, drop attacks, and perioral or limb numbness. Reproducible brainstem symptoms on sustained head rotation are the hallmark of RVAS and warrant urgent vascular workup.
C1–C2 segment (atlantoaxial joint, atlas-axis): The atlantoaxial joint, between the first (atlas) and second (axis) cervical vertebrae. Approximately 50% of cervical rotation occurs at C1–C2, and the densest proprioceptive afference in the cervical spine surrounds this segment. Dysfunction here disproportionately disturbs the head-position signal.
Caloric test (calorics, bithermal caloric): Irrigation of the external auditory canal with warm and cool water (or air) to thermally stimulate the lateral semicircular canal. Asymmetric responses (canal paresis >25% by Jongkees formula) indicate unilateral peripheral vestibular hypofunction. Distinct from vHIT in that calorics test only the lateral canal at low frequencies.
Canalithiasis (free-floating otoconia): The pathological state in which free-floating otoconia move within the lumen of a semicircular canal under gravity, producing brief positional vertigo (BPPV). Distinct from cupulolithiasis, where otoconia adhere to the cupula. Canalithiasis produces fatigable, latent nystagmus; cupulolithiasis is non-fatiguing.
Central cervical nucleus (CCN): A relay nucleus in the upper cervical cord (C1–C3) that receives proprioceptive afferents from the deep neck muscles and joints and projects to the vestibular nuclei, where neck input integrates with labyrinthine input. The functional gateway through which cervical proprioception reaches the central balance pathways.
Central reweighting (sensory reweighting, visual dependence): An adaptive process by which the brain shifts its sensory weighting when one input becomes unreliable. In chronic cervicogenic patients, prolonged altered cervical input leads to over-reliance on vision — producing the supermarket, scrolling, and crowd-environment symptoms of Route 4. Requires retraining rather than further manual therapy.
Cervical Torsion Test (CTT, trunk-on-head test): A bedside test in which the patient's head is held still while their trunk is rotated underneath, stimulating cervical receptors without moving the vestibular system. Reproduction of dizziness implicates the cervical receptors. The defining feature is that the vestibular system stays in the same gravitational position throughout.
Cervico-ocular reflex (COR): A complementary reflex to the VOR that uses neck-derived (rather than labyrinthine) input to stabilise gaze during head-on-trunk and trunk-on-head movements. Normally subordinate to the VOR but can be up-regulated in vestibular hypofunction.
Cervicogenic dizziness (cervical vertigo, neck-related dizziness): A clinical entity in which dizziness or unsteadiness arises from disturbed cervical afferent input. A diagnosis of exclusion: peripheral vestibular and central causes must be excluded first. Four mechanism routes are recognised: proprioceptive mismatch, vestibulo-sympathetic loop, RVAS, and central reweighting / chronic.
Cupulolithiasis (adherent otoconia): Otoconia adherent to the cupula of a semicircular canal, producing sustained positional vertigo and non-fatiguing apogeotropic nystagmus in the lateral canal variant. Less common than canalithiasis and often more resistant to repositioning.
Deep neck flexors (longus colli, longus capitis, DCF): The longus colli and longus capitis muscles that lie deep along the anterior cervical spine. They are crucial postural stabilisers of the head-on-neck, and their dysfunction is a recurring finding in cervicogenic dizziness. Deep cervical flexor strengthening is a core component of Route 1 management.
Dix-Hallpike manoeuvre (DH, Dix Hallpike test): The diagnostic test for posterior canal BPPV. The patient is brought from upright to supine with the head turned 45° toward the tested side and extended 20° below horizontal. Positive when a characteristic upbeating-torsional nystagmus is provoked after a brief latency, with associated vertigo. Always performed BEFORE any cervical provocation in the workup of dizziness with neck pain.
Dizziness Handicap Inventory (DHI): A 25-item patient-reported outcome quantifying the impact of dizziness across physical, emotional, and functional subscales (Jacobson & Newman 1990). Total scores 0–100; bands: 0–30 mild, 31–60 moderate, 61–100 severe. Minimum clinically important difference ≈ 18 points. Tracks change with treatment.
Dynamic Doppler (transcranial Doppler, TCD with rotation, dynamic vertebral artery Doppler): Doppler interrogation of the vertebral arteries in neutral and provocative head positions. The screening investigation for RVAS — loss of end-diastolic velocity in V3 on sustained rotation, with the contralateral side preserved, is the early haemodynamic signature. Confirmatory imaging is dynamic CTA or catheter angiography.
Epley manoeuvre (canalith repositioning procedure, CRP): First-line treatment for posterior canal BPPV. Five-step sequence that moves otoconia out of the posterior canal and back into the utricle. Approximately 80% single-session success. AAO-HNS 2017 makes a strong recommendation AGAINST post-procedure postural restrictions.
Geotropic nystagmus (earth-bound nystagmus): Nystagmus beating toward the lower ear (toward the earth) on supine roll testing. In lateral canal BPPV, geotropic nystagmus indicates canalithiasis. The affected ear is the side where the response is more intense.
Habituation exercises (Brandt-Daroff, vestibular habituation): A treatment approach using graded, repeated provocation of dizziness-triggering positions to desensitise the central response over time. Useful for some forms of motion-provoked dizziness and as a second-line BPPV strategy. CONTRAINDICATED in RVAS, where habituation may worsen the underlying vascular event.
HINTS examination (Head Impulse Nystagmus Test of Skew): A three-step bedside battery used to distinguish peripheral from central causes of acute vestibular syndrome. Comprises Head Impulse Test, Nystagmus characterisation, and Test of Skew. A 'peripheral' HINTS pattern (abnormal head impulse, unidirectional horizontal nystagmus, no skew) is more sensitive than early MRI for stroke exclusion in the acutely dizzy patient.
Interaural Asymmetry Ratio (IAR, VEMP asymmetry): A quantitative measure of side-to-side VEMP amplitude difference, calculated by the Jongkees formula: 100 × |L − R| / (L + R). IAR > 35% is generally considered abnormal and suggests asymmetric saccular or inferior vestibular nerve function.
Joint Position Error (JPE, head repositioning accuracy): A test of cervical proprioceptive accuracy in which the blindfolded patient is asked to return their head to a remembered neutral position after rotation. Error >4.5° on cervical rotation (Revel 1991) is considered abnormal and is reproducibly elevated in cervicogenic dizziness, more so on the side of greatest proprioceptive disturbance.
Labyrinth (vestibular) (inner ear, membranous labyrinth): The membranous balance organ within the temporal bone, comprising three semicircular canals (anterior, posterior, lateral) sensing angular acceleration and two otolith organs (utricle, saccule) sensing linear acceleration and head tilt. Together they generate the labyrinthine signal that integrates with cervical and visual input in the vestibular nuclei.
Lateral canal BPPV (LC-BPPV, horizontal canal BPPV): BPPV variant involving the lateral (horizontal) semicircular canal. Produces direction-changing horizontal nystagmus on supine roll testing. Geotropic variant (canalithiasis) responds to the Lempert barbecue roll; apogeotropic (cupulolithiasis) is treated with Gufoni or modified manoeuvres.
Lempert barbecue roll (BBQ roll, Lempert 270° roll, log roll): First-line therapeutic manoeuvre for geotropic lateral canal BPPV. The patient is rolled 270° around the long axis (in 90° increments toward the unaffected side) to flush otoconia out of the lateral canal and back into the utricle.
Muscle spindle (intrafusal fibre): A stretch-sensitive sensory receptor embedded within skeletal muscle. The deep suboccipital muscles carry the highest density of muscle spindles in the body — up to 200 spindles per gram — making them the dominant cervical proprioceptive source. Spindle dysfunction underpins the proprioceptive mismatch of Route 1.
Neck Disability Index (NDI): A 10-section patient-reported outcome measuring neck-pain-related disability (Vernon & Mior 1991). Raw 0–50 (or 0–100% doubled). Bands: 0–4 none, 5–14 mild, 15–24 moderate, 25–34 severe, ≥35 complete. MCID ≈ 5 raw points. Useful as a baseline and for tracking change.
Persistent Postural-Perceptual Dizziness (PPPD, chronic subjective dizziness): Persistent (≥3 months) non-vertiginous dizziness or unsteadiness, exacerbated by upright posture, motion, and exposure to busy visual environments (Staab 2017 criteria). Often follows an acute vestibular event. First-line pharmacotherapy is an SSRI or SNRI; vestibular rehabilitation with graded exposure is the cornerstone.
Posterior canal BPPV (PC-BPPV, posterior canalithiasis): The most common BPPV variant. Otoconia in the posterior semicircular canal produce brief upbeating-torsional nystagmus on Dix-Hallpike. Responds to Epley repositioning, with single-session success around 80%.
Proprioception (position sense, kinaesthesia): The sense of self-position and movement of body parts in space, derived primarily from muscle spindles, Golgi tendon organs, and joint receptors. Cervical proprioception is dominated by the deep suboccipital muscles and is the foundation of the proprioceptive cervicogenic mechanism (Route 1).
Rotational Vertebral Artery Syndrome (RVAS, Bow Hunter syndrome, Bow Hunter's stroke): Mechanical compression of the dominant vertebral artery on sustained head rotation, producing transient brainstem features that resolve on returning to neutral. Requires a structural compression source (osteophyte, fibrous band, atlantoaxial instability) and inadequate contralateral collateral flow. Manipulation is contraindicated.
Semont liberatory manoeuvre (Semont): Alternative therapeutic manoeuvre for posterior canal BPPV using rapid lateral position changes rather than head rotation. Useful when cervical extension is limited or painful. Similar efficacy to Epley in network meta-analysis.
Sensorimotor control (cervical sensorimotor, neuromotor control): The integrated process by which sensory information (proprioceptive, vestibular, visual) is processed centrally to produce coordinated motor output for posture and gaze. Cervical sensorimotor retraining — addressing JPE, oculomotor control, balance, and movement sense — is a Level-2-evidence cornerstone of Route 1 management (Sremakaew 2023).
Sensory Organisation Test (SOT, posturography, computerised dynamic posturography): A computerised dynamic posturography protocol that scores postural sway across six conditions varying visual and proprioceptive feedback. Visual-preference patterns (abnormal in conditions 3 and 6, preserved 5) suggest central reweighting toward visual cues; pure proprioceptive deficit shows abnormal 4, 5, 6.
Smooth Pursuit Neck Torsion test (SPNT): Measures smooth-pursuit gain in two conditions: head and trunk aligned, then trunk rotated 45° under a stationary head. A gain difference >0.10 between the two conditions implicates abnormal cervical afference, since the vestibular system is in the same position in both conditions.
Spurling test (foraminal compression test): Cervical extension and lateral flexion toward the symptomatic side with axial compression. Reproduction of radicular pain suggests cervical nerve root compression. A negative test argues against radiculopathy but does not address proprioceptive cervicogenic dizziness mechanisms.
Suboccipital muscles (rectus capitis posterior major and minor, obliquus capitis, SO muscles): The four deep posterior muscles connecting the upper cervical vertebrae to the occiput: rectus capitis posterior major, rectus capitis posterior minor, obliquus capitis superior, obliquus capitis inferior. They contribute about half of cervical rotation at C1–C2 and carry the densest proprioceptive afference in the cervical spine.
Supine roll test (Pagnini-McClure test, roll test): The diagnostic test for lateral canal BPPV. The patient lies supine with the head flexed 30° (placing the lateral canal in the vertical plane), then the head is rapidly rolled 90° to each side. Direction of provoked nystagmus distinguishes geotropic (toward the earth — canalithiasis) from apogeotropic (toward the ceiling — cupulolithiasis) variants.
Vertebral artery (VA, V3 segment): The paired arteries running through the transverse foramina of C6 to C1, supplying the brainstem and posterior cerebral circulation. The V3 segment (between C2 and the foramen magnum) is the most mobile portion and is the typical site of mechanical compression in rotational vertebral artery syndrome (RVAS).
Vestibular Evoked Myogenic Potential (VEMP, cVEMP, oVEMP): Short-latency myogenic potentials elicited by intense sound or vibration. Cervical VEMP (cVEMP, recorded from the sternocleidomastoid) tests the saccule and inferior vestibular nerve; ocular VEMP (oVEMP, recorded from inferior oblique) tests the utricle and superior vestibular nerve. Unilateral amplitude reduction localises to the saccule/inferior nerve pathway and warrants further investigation.
Vestibular migraine (VM, migrainous vertigo): Discrete vestibular attacks (5 minutes to 72 hours) accompanied by migrainous features (photophobia, phonophobia, headache, aura) in a patient with a migraine history. The most commonly missed alternative explanation for the neck-pain-plus-dizziness presentation. Premonitory neck stiffness in the 24 hours before an attack is a recognised feature.
Vestibular neuritis (acute vestibular syndrome, labyrinthitis (if hearing involved)): Acute prolonged spontaneous vertigo with characteristic HINTS pattern: positive head impulse to the affected side, unidirectional horizontal nystagmus, no skew. No hearing loss (its presence suggests labyrinthitis). Severe for days, then settles over weeks to months as central compensation develops.
Vestibular nuclei (VN): Four paired nuclei in the lateral medulla — superior, lateral (Deiters'), medial, and inferior. They receive vestibular afferents from the labyrinth, cervical afferents via the central cervical nucleus, and visual input, and they project to oculomotor nuclei (for the VOR), the spinal cord (vestibulospinal), and the cerebellum. The central integrator of head-position information.
Vestibular schwannoma (acoustic neuroma, VS): A benign tumour arising from the Schwann cells of the vestibular nerve, classically presenting with progressive asymmetric sensorineural hearing loss, tinnitus, and a vague unsteadiness. Vestibular tests show progressive ipsilateral hypofunction. MRI with internal-auditory-meatus protocol is the imaging investigation of choice.
Vestibulo-ocular reflex (VOR): The reflex that stabilises gaze during head movement by driving the eyes in the opposite direction at equal velocity (VOR gain ≈ 1.0). Tested clinically by the head impulse test (bedside) or video head impulse test (instrumented). Reduced gain indicates peripheral vestibular hypofunction.
Vestibulo-sympathetic loop (VS loop, autonomic vestibular pathway): Projections from the vestibular nuclei to brainstem autonomic centres (rostral ventrolateral medulla, nucleus of the solitary tract) that mediate the autonomic accompaniments of vestibular signals — nausea, pallor, sweating, palpitations. Drives the Route 2 cervicogenic presentation, where autonomic features dominate.
Video Head Impulse Test (vHIT, video head impulse): A bedside test measuring the angular VOR by delivering brief unpredictable head impulses while video-tracking the eyes. Reduced gain (<0.8) with corrective saccades on one side indicates ipsilateral peripheral vestibular hypofunction. Should be NORMAL in pure cervicogenic dizziness; an abnormal vHIT mandates investigation for a peripheral cause.

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