Is the Neck Causing Dizziness? How to Tell

Dizziness is one of those presentations that can quickly feel uncertain. Patients often struggle to describe what they’re experiencing, and as clinicians, we’re left trying to piece together whether the source is vestibular, visual, cervicogenic, or something else entirely.

Cervicogenic dizziness is something we’re well placed to manage, but it’s rarely straightforward to identify. It doesn’t present with clear-cut features, and there’s no single test that confirms it. Instead, it sits within a broader clinical reasoning process.

In her Case Study, expert neck physiotherapist Dr Julia Treleaven provides a detailed look at her clinical reasoning across both assessment and management. In this blog, we’ll focus on how she approaches the assessment of a patient presenting with dizziness, and how to answer a question we’re all familiar with: what role is the neck actually playing?

If you want to see exactly how an expert physio assesses and manages dizziness, watch Dr Julia Treleaven’s full Case Study HERE. With Case Studies you can step inside the minds of experts and apply their strategies to get better results with your patients. Learn more here.

The case

Sue is a 58-year-old with a history of chronic left-sided neck pain and headaches, who presents with dizziness that has developed over the past few months. Her symptoms are described as intermittent unsteadiness, alongside visual disturbance and nausea, particularly aggravated by reading, driving, and looking at her phone.

Importantly, Sue does not describe true spinning vertigo. Instead, her dizziness feels more like light-headedness and unsteadiness, with associated visual symptoms. That distinction matters. If she were reporting true vertigo, hearing loss, or neurological signs, your clinical reasoning would likely shift quite quickly.

There are also some clear patterns. Her symptoms are aggravated by sustained tasks and certain neck positions, and they tend to build throughout the day rather than occurring as distinct episodes.

At the same time, there are several competing factors in her history. She has a history of migraine with aura, has previously experienced Benign Paroxysmal Positional Vertigo (BPPV), and has been under significant stress. Visual triggers such as driving and screen use also seem to play a role.

At this point, the goal isn’t to find a single cause, but to start weighing up which systems may be contributing.

Considering other possibilities

Before settling on a cervical contribution, it’s important to keep other differentials in mind.

Vestibular migraine remains a possibility, particularly given her migraine history, although she is not reporting clear spontaneous episodes of vertigo. A psychogenic component could also be considered, especially if symptoms were described as a vague sense of detachment or accompanied by features such as hyperventilation or chest tightness. Visual dysfunction is another potential contributor, particularly when symptoms are provoked by tasks like reading or driving.

Rather than ruling these out immediately, they remain part of the broader picture as you move into your assessment.

What raises suspicion of a cervical contribution?

Cervicogenic dizziness tends to sit in a grey area. Symptoms are often described as unsteadiness rather than spinning, and there is usually some relationship with neck movement or position. Visual disturbance is common, and symptoms tend to fluctuate rather than present as distinct episodes.

Equally important are the features that don’t fit. There are no clear neurological signs, no hearing changes, and no strong triggers such as loud noise or coughing. The presentation doesn’t neatly align with a classic vestibular condition, but it doesn’t exclude it either.

At this stage, you’re not trying to confirm a diagnosis. You’re building a working hypothesis and looking for ways to test it. See Julia explain how to determine the role of the cervical spine in this clip from her Case Study:

Physical examination

Cluster of cervical musculoskeletal tests

On examination, Sue presents with clear musculoskeletal findings. Her cervical range is reduced, particularly into flexion-rotation and lateral flexion to the left. There are positive joint signs at C0–1, along with stiffness through the cervicothoracic and thoracic regions. Her deep neck flexor control is poor, with a tendency to retract.

Taken together, this gives you a clear picture of cervical impairment. But, while these findings tell you that the neck is impaired, not that it’s causing the dizziness. Many patients will present with similar cervical findings without any dizziness at all. So if you stop here, you risk over-attributing the problem to the neck.

To understand its role, you need to look at how the system is functioning.

Sensorimotor examination

With Sue, there are subtle but important changes. Her balance is relatively stable with vision, but becomes less controlled with eyes closed, and even more so when the neck is placed in torsion. When walking, larger and slower head movements increase her dizziness, whereas smaller movements are better tolerated.

There are also clear issues with coordination. Her trunk and head don’t move particularly well together, and her ability to coordinate eye and head movements is reduced on both sides. Oculomotor tasks provoke mild symptoms, and there is some sensitivity to visual motion. See Julia explain part of her sensorimotor assessment in this video from her Case Study:

Using movement to isolate the source

One of the most useful strategies in this assessment is comparing how symptoms behave under different conditions.

If symptoms increase when cervical input is emphasised, that gives you valuable information. If they change depending on whether the head moves independently of the trunk, or whether vision is removed, you can start to tease apart which systems are involved.

In Sue’s case, symptoms are more pronounced when cervical input is biased. Larger head movements are more provocative than smaller ones, torsion increases her symptoms compared to neutral, and isolating cervical movement tends to increase her dizziness more than moving the body as a whole.

This doesn’t prove the neck is the sole driver, but it does suggest it’s playing a role.

Clinical reasoning

Julia concludes that Sue’s presentation isn’t purely cervical. There are likely multiple factors involved, including stress and some degree of visual sensitivity, with a possible vestibular component as well.

However, there is also a consistent pattern pointing towards a mild to moderate cervical contribution. Her symptoms are linked to neck movement and position, she presents with a clear cluster of cervical impairments, and her sensorimotor findings change when cervical input is altered.

Wrapping up

Dizziness rarely fits neatly into one category, particularly in older adults. If we rely on single tests or try to force a diagnosis too early, we risk oversimplifying what is often a multi-system presentation.

The history guides your thinking, the musculoskeletal examination highlights potential contributors, and sensorimotor testing helps you understand how these systems interact. Together, this gives you a clearer picture of the role the cervical spine may be playing. From here, you can form an initial hypothesis to guide your treatment, while remaining ready to adapt based on how the patient responds.

Want to see how Julia assessed and went on to manage this patient? Watch her full Case Study here.