WHAT IS CAUSING MY DIZZINESS?

Dizzy pic

Are you getting dizzy?  Feeling light headed?  Does the room spin?  Like your on a boat?

 

When considering how to approach dizziness I discuss with my patient these 4 areas of the body that can result in dizziness:

 

1.       Neck

2.       Ears

3.       Brain

4.       Eyes

 

 

 

 

 

 

1.       Neck (cervicogenic)

 

The most overlooked balance centre is the neck, particularly the upper neck.  How overlooked is it? 

This study of 1000 patients who presented to a Japanese hospital emergency room with the primary complaint of dizziness found that in 89% of those cases the dizziness was caused by the neck.  This is known as cervicogenic dizziness.[i]   

The upper neck joints, muscles and ligaments are the most neurologically sensitive structures in the body.  These delicate structures have many functions.  One function is that of a sensory organ, providing a huge amount of information to the brain about head and body position.   

Damage to these structures or disruption to the normal posture or alignment results in poor information being relayed to the brain and may result in dizzy symptoms.  Particularly if the information from the neck does not match the information from the eyes or ears as would be the case with many neck problems.  

The brain gets confused when the eyes and ears are telling it one thing about your position while the neck is saying something else.  For example if the eyes and ears tell the brain you are standing upright looking straight ahead, but the neck is misaligned and telling the brain your head is slightly tilted there is a mismatch.  This confusion may result in dizziness, particularly when you move your head and neck.

It is one of the more common symptoms to occur with neck injury such as whiplash, concussion or damage to the neck from degenerative issues such as arthritis, disc injury or muscle disruption.  

It can happen to people of all ages as a result of neck problems.  Its incidence may be as high as 90% following whiplash injury and in adults with neck pain studies looking at the incidence of dizziness range from 20-90%[ii]. 

Interestingly whilst most people who experience cervicogenic dizziness describe “light headedness” about 15-20% experience spinning vertigo which is very hard to distinguish from BPPV (from the ears)[iii]. 

This could explain why some people who are diagnosed with BPPV do not get relief.       

 

FUN FACT:  To give you an idea of just how neurologically sensitive the upper neck is there is a muscle in the upper neck called the OBLIQUUS CAPITIS INFERIOR MUSCLE which holds the record in the body for having the most muscle spindle cells per gram of muscle in the body at 242.[iv] These muscle spindles send information to the brain about tension in the muscles.  For comparison, another better known neck muscle, the trapezius (which is commonly associated with neck tension) has only 2 muscle spindles per gram.  That is over 100 x more information about muscle tension from that tiny upper neck muscle.  The brain uses information from the upper neck to control  balance.  So if you have neck symptoms, such as tension or dizziness, do you think they are more likely to come from the lower neck which is less active neurologically or the upper neck which sends up to 100 x as much information to the brain about balance and tension? 

 

OBLIQUUS CAPITIS INFERIOR MUSCLE – THE TENSION AND BALANCE CONTROL MUSCLE[v]

 

2.  Ears

 

 

Inside the middle ear is a balance control mechanism known as the vestibular apparatus.  It is made up of a series of semicircular canals which are lined by tiny hairs.  Inside the canals flows a thick fluid called endolymph.  As the fluid flows in a certain direction it moves the tiny hairs with it, much like seaweed attached to the rocks moves with the waves.  These hairs are attached to nerves which send a message to the brain about the movement and position of the head.  The fluid inside the canals will move the hairs in different directions depending on if we are bending or rotating in different directions.  These signals are then carried along the vestibular nerves to be processed by the brain. 

Debris such as broken hairs, or other debris termed “otoliths” can build up in the canals and interfere with the normal free movement of the hairs with the fluid.  This causes some hairs to send a signal that they are moving one direction, whilst others send conflicting signals saying they are not moving that way.  This results in sudden, often very severe vertigo/dizziness where the room spins. 

This is called benign paroxysmal positional vertigo or (BPPV). 

BPPV is estimated to account for around 8% of moderate to severe vertigo cases[vi].  

It occurs during certain head positions such as lying back or to the side in bed. 

 

3.  The Brain

The brain receives information from the body such as joint position, connective tissue and muscle tone to form an image of itself in space every moment of every day.  This is called proprioception. 

It then uses this perceived image of itself to send signals back to the body to appropriately respond to the situation.   

Dysfunction in the brain can cause problems with processing the incoming sensory information.  This may result in dizziness. 

Dysfunction may be caused by degeneration, concussion, brain damage, lack of blood flow or oxygen as just a few examples. 

More serious examples of brain dysfunction resulting in dizziness include conditions such as strokes, aneurisms, tumors and other space occupying lesions.   

So, while it is unlikely in the majority of dizziness cases to be due to a serious or life threatening brain condition it is important to rule out the serious medical causes.

 

4. EYES

 

Our eyes send information to the visual processing center's of our brain which then forms an image about our surroundings and our position in space. 

In order to feel balanced the image created in our mind from our eyes must match the image formed from our ears and neck. 

If the eyes and ears are saying we are upright, while the neck is saying we are tilting on an angle the brain becomes confused and causes dizziness. 

Part of the assessment of a dizzy patient should involve assessing eye movements head and neck movements.  These tests often indicate that dizziness is caused by a disconnect between information coming from the eyes to that of either the ears or neck.  

 

OTHER CAUSES OF DIZZINESS

 

-          Cardiovascular: Heart failure, low blood pressure, valve issues etc:  Basically any heart condition which results in difficulty pumping oxygen to the brain may cause dizziness and should be ruled out in the dizzy patient.

-          Stress

-          Medication side effects – if suspected speak to a medical provider or pharmacist.

-          Ear infection

-          Migraine

-          Low blood sugar

-          Dehydration

-          Anxiety

 

If I’m dizzy what should I do?

1.       Make sure its not serious. 

Is your heart ok?  Is your brain ok?  Your medical provider can refer you for the appropriate scans and tests to rule out the serious medical causes. 

 

2.       Check the ears and rule out BPPV. 

Typically BPPV is simple to find and simple to resolve.  In my experience it will require only 1 or 2 manoeuvres to resolve. 

All chiropractors, physiotherapists and many medical professionals are trained in how to check and treat BPPV. 

This is done with testing such as the dix-hallpike test and treated with manoeuvres to tip out or relocate the debris from the middle ear canals such as Epleys manoeuvre. 

If the practitioner has had experience with BPPV this is should be simple to address. 

 

WHAT IF NOTHING WAS FOUND ON HEAD SCANS AND THE EPLEY MANOEVRE DID NOT WORK?

 

3.       Get your neck checked.  The neck is the most likely cause.   When tests for medical pathology of the head show nothing abnormal, tests for BPPV are negative or epleys manoeuvre did not solve the dizziness it is quite likely to be caused from the neck.  Chiropractors are very well positioned to assess and address issues with the neck.  Not all chiropractic approaches are appropriate for the dizzy patient however. 

 

 

 

UPPER CERVICAL SPECIFIC CHIROPRACTIC CARE

 

 

Upper cervical specific chiropractic techniques such as the Blair technique, Nucca, atlas orthogonal, grostic etc would be my preferred approach.  I use the Blair technique.  Upper cervical specific chiropractic techniques are a very niche group of techniques which focus entirely on the alignment and neurological consequences of the upper neck.  These techniques are very different to the more well known techniques that involve audible clicks and pops when the neck is adjusted.  The Upper cervical specific approach is very gentle and very precise.  Adjustment are done resting on your side and use very low force.  They are performed without any head or neck twisting and do not involve any popping or cracking noises.  In fact it was due to exploring the success of the Blair technique in helping reduce dizziness in a particular group of patients that I became more aware, and eventually decided to do the post graduate training to be one of the few chiropractors in Australia who are proficient in one of the upper cervical specific chiropractic techniques.

 

How does upper cervical chiropractic care help dizziness?

 

Every upper cervical chiropractor, myself included will have seen many cases of dizziness resolve after improving the neck alignment and function.  The fascinating part for me is understanding why it happens?  While each case is different there are several mechanisms which help to explain the results.  These are some of the mechanisms that authors have proposed which could result in cervicogenic dizziness[vii]:

 

 

1. Inflammation of the atlanto-Occipital (upper cervical spine) articulation (joint) with edema putting pressure on adjacent structures, i.e., the Eustachian tube.

 

 

2. Traction, irritation, dysfunction of Cranial nerves VII through XII (facial, vestibulocochlear, glossopharyngeal, vagus, accessory and hypoglassal) also Jacobson’s (provides nerve supply to the middle ear and eustacian tube) and Arnold’s nerves(nerve supply to the ear canal).  These nerves all branch off the brainstem in close proximity to the craniocervical (head/neck) junction

 

 

3. Irritation/facilitation of the Trigeminocervical nucleus and tract.

 

 

4. Irritation of the sympathetic nerves can elicit spasms within the vertebral artery, leading to a decrease in blood flow to the brainstem.

 

 

5. Chronic CSF “backjets” into the fourth ventricle due to obstruction of outflow through the foramen magnum may affect the flocculonodular lobe of the cerebellum resulting in nystagmus, vertigo and balance disorders.

 

 

6. The endolymphatic sac performs absorptive and secretory, as well as phagocytic and immunodefensive, functions. It is innervated by the superior cervical ganglion, which is located laterally adjacent to C2, axis. If these nerves are irritated by the upper cervical spine it can send amplified sympathetic signals to the sac.

 

7. Altered proprioception.  If bad information goes into the brain from altered stretch, tension, compression of structures in the upper cervical spine dizziness may be triggered.

 

While the mechanisms are complex and may be varied for each individual there is no doubt that improving the alignment and function of the neck which is the sole focus of an upper cervical specific chiropractor results in relief of dizziness for many patients.

 

Conclusion:

 

Dizziness is a very common symptom.  Cervicogenic dizziness, caused by neck problems is one of, if not the most common causes.  It makes sense to rule out the serious medical causes 1st.  It then makes sense to get your neck checked.  Chiropractors, are well positioned to assess your neck.  In my experience upper cervical specific chiropractic techniques which focus exclusively on the upper neck alignment would be my recommendation.

 

 

FINDING AN UPPER CERVICAL SPECIFIC CHIROPRACTOR:

https://www.uppercervicalcare.com/

 

[i] Takahashi, Sho. (2018) Importance of cervicogenic general dizziness. J.Rural Medicine. May; 13(1): 48–56 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5981019/

 

 
[ii] Vural, M et al. (2021) Prevalence, etiology, and biopsychosocial risk factors of cervicogenic dizziness in patients with neck pain: A multi-center, cross-sectional study. Turk J. Phys Med Rehab. 67(4), 399-408 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8790272/

 

 
[iii] Reiley, A. et al. (2017). How to diagnose cervicogenic dizziness. Archives of Physiotherapy. Vol 7.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5759906/

 
[iv] Kulkarni et al (2001). Quantitative study of muscle spindles in suboccipital muscles of human foetuses. Neurol. India. 49(3). 355-359.  https://pubmed.ncbi.nlm.nih.gov/11799407/

 

 
[v] Kulkarni et al (2001). Quantitative study of muscle spindles in suboccipital muscles of human foetuses. Neurol. India. 49(3). 355-359.  https://pubmed.ncbi.nlm.nih.gov/11799407/

 
[vi] Von Brevern et al (2007) Epidemiology of benign paroxysmal positional vertigo: a population based study. J. Neurol Neurosurg. Psych. 78(7). 710-715 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2117684/

 

 
[vii] Burcon, M (2016), “Health Outcomes Following Cervical Specific Protocol in 300 Patients with Meniere’s Followed Over Six Years,” J Upper Cervical Chiropractic Research, June 2, 2016 https://www.researchgate.net/publication/303784426_Health_Outcomes_Following_Cervical_Specific_Protocol_in_300_Patients_with_Meniere's_Followed_Over_Six_Years