Dizziness & Vertigo

Written by Dr Steven Hewitt — Chiropractor · AHPRA: CHI0001115420 · Last reviewed: May 2026

The first and most important task with any dizziness presentation is differentiating between conditions that are appropriate for musculoskeletal management and conditions that require urgent medical assessment. Dizziness associated with sudden severe headache, neurological symptoms (diplopia, dysarthria, dysphagia, facial numbness), loss of consciousness, or following neck trauma requires urgent medical evaluation before any manual assessment or treatment. The conditions described on this page are benign musculoskeletal presentations — but that classification depends on appropriate screening.

Among the musculoskeletal causes of dizziness, BPPV and cervicogenic dizziness are the two most common. They are often confused with each other — and occasionally co-exist — but they have distinct mechanisms and require different management approaches.

BPPV: A Mechanical Problem With a Mechanical Solution

Benign paroxysmal positional vertigo is caused by displaced calcium carbonate crystals (otoliths or "ear rocks") in the semicircular canals of the inner ear. When the head moves into certain positions, these crystals create abnormal fluid movement within the canal, generating brief episodes of intense rotatory vertigo — typically lasting 10 to 60 seconds, triggered by rolling over in bed, looking up, or bending forward.

The diagnosis is clinical: the Dix-Hallpike test is the gold standard for posterior canal BPPV (the most common variant), producing a characteristic torsional nystagmus when positive. The test is both diagnostic and — in combination with the history — sufficient to guide treatment in the majority of cases without imaging.

The Epley canalith repositioning manoeuvre — a sequence of head and body positions that guides the displaced crystals back into the utricle — resolves BPPV in the majority of cases within one to three sessions. A 2014 Cochrane review confirmed the Epley manoeuvre is significantly more effective than sham treatment and produces immediate resolution of vertigo in approximately 80% of posterior canal BPPV cases. [1] BPPV is one of the most straightforwardly treatable conditions in musculoskeletal practice — when correctly identified and correctly treated. → BPPV

Cervicogenic Dizziness: A Proprioceptive Problem

Cervicogenic dizziness (CGD) is not a vestibular condition. It arises from disrupted proprioceptive signalling from the cervical spine — specifically from the mechanoreceptors in the upper cervical joints and periarticular tissues, which normally contribute to spatial orientation, gaze stabilisation, and postural control.

The upper cervical segments — C1, C2, and C3 — have the highest density of proprioceptive receptors in the spine, reflecting their role in head-on-trunk orientation. These afferents feed into the vestibulocerebellar system and the trigeminocervical nucleus, contributing to the integrated balance signal. When upper cervical joint dysfunction, muscle guarding, or fascial restriction alters the quality of proprioceptive input from this region, the vestibular system receives conflicting information — and the subjective experience is dizziness, often accompanied by neck pain and unsteadiness rather than true rotatory vertigo. [2]

Distinguishing CGD from BPPV involves noting that CGD dizziness is typically constant or prolonged (rather than episodic and brief), associated with neck movement or sustained postures (rather than specific head positions), and accompanied by cervical pain and stiffness. It does not produce the nystagmus of BPPV on the Dix-Hallpike test. A systematic review and meta-analysis by De Vestel and colleagues demonstrated that cervical manual therapy — targeting the upper cervical joints and suboccipital soft tissues — significantly reduces dizziness in cervicogenic dizziness compared to control conditions. [3] → Cervicogenic Dizziness

The Cervical Spine and the Balance System

Whether the presentation is BPPV, cervicogenic dizziness, or an overlap between the two, the cervical spine is a component of the clinical picture. In BPPV, the repositioning manoeuvre requires precise cervical and head positioning — and cervical restriction that limits head extension or rotation can impede effective treatment. In cervicogenic dizziness, the cervical spine is the primary treatment target.

Beyond these two conditions, the connection between cervical dysfunction and vestibular symptoms is broader than commonly appreciated. The trigeminocervical nucleus — where cervical nociceptive and proprioceptive afferents converge with trigeminal input — projects to the vestibulocerebellar pathway. Upper cervical dysfunction can therefore amplify vestibular symptoms even in conditions with a primary vestibular cause, and cervical treatment can reduce symptom burden in presentations where the vestibular component appears primary. [4]

Assessment of a dizziness presentation at this clinic includes screening for central nervous system involvement, vestibular testing (Dix-Hallpike, head impulse, HINTS protocol), and cervical assessment including joint mobility, muscle function, and proprioceptive testing — because identifying the primary driver determines the appropriate treatment.

What Can You Do Right Now?

Document your dizziness precisely. The timing, duration, triggers, and associated symptoms are what distinguish BPPV from cervicogenic dizziness from more serious causes. A brief diary noting: when dizziness occurs, what position or movement triggered it, how long each episode lasts, and whether neck pain accompanies it will make your clinical assessment significantly more efficient.

Avoid prolonged upper cervical extension. Extended periods in neck extension — looking up at a ceiling, lying flat without pillow support, certain overhead activities — can aggravate both BPPV (by shifting loose otoliths) and cervicogenic dizziness (by compressing upper cervical structures). Keeping the head in a neutral or slightly supported position is a reasonable precaution while the cause is being investigated.

Do not attempt self-treatment of BPPV without a confirmed diagnosis. The Epley manoeuvre applied to the wrong canal variant, or to cervicogenic dizziness mistaken for BPPV, can worsen symptoms. Diagnosis with the Dix-Hallpike test or other positional tests should precede repositioning manoeuvres.

Address cervical stiffness actively. For cervicogenic dizziness in particular, improving upper cervical mobility and suboccipital muscle quality is a direct treatment target. Gentle cervical rotation in sitting — maintaining a neutral chin position and rotating smoothly to each side within a comfortable range — stimulates cervical mechanoreceptors and can reduce proprioceptive disruption over time when performed consistently.

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