Dizziness and Vertigo: Is It Your Neck or Your Inner Ear?

You roll over in bed and the room takes off. Or you stand up, reach for something on a high shelf, and the world tilts for a few seconds before it settles. Maybe it is subtler than that: a constant fogginess, a sense that the floor is not quite where it should be, which gets worse the longer you sit at your desk.

These are all called dizziness, but they are not the same problem. The most common cause sits in your inner ear. A less common one sits in your neck. They respond to completely different treatments, which is why getting the distinction right matters more than almost anything else here.

Dizziness, vertigo and light-headedness are different things

Being precise about what you are feeling is genuinely useful, because it narrows the possibilities fast.

Vertigo is a false sense of movement. The room spins, tilts or slides. It is usually a problem with the inner ear or the balance pathways in the brain.

Light-headedness is the feeling that you are about to faint. It is more often related to blood pressure, dehydration, medication or blood sugar than to your ears or your neck.

Unsteadiness or disequilibrium is a sense of being off balance without the room actually spinning. People describe it as floating, swimming or walking on a boat. This is the category that neck-related dizziness usually falls into.

If you can work out which of these three you are experiencing, you have already done a large part of the diagnostic work.

The most common cause: BPPV

Benign paroxysmal positional vertigo is the single most common cause of vertigo, accounting for more than half of all peripheral vertigo cases. In a population study of nearly 4,900 adults, the lifetime prevalence was 2.4%, and it was twice as common in women as in men (von Brevern et al., 2007).

Despite the reassuring name, it is not a trivial condition. In that same study, 86% of people with BPPV had to consult a doctor, interrupt their daily activities or take sick leave because of it.

What is actually happening

Your inner ear contains three fluid-filled semicircular canals that detect head rotation. Nearby sit tiny calcium carbonate crystals called otoconia, which normally stay put and help you sense gravity and linear movement.

In BPPV, some of those crystals come loose and drift into one of the canals, most often the posterior canal. When you move your head, the crystals move through the fluid and drag it with them, sending your brain a signal that says you are spinning when you are not. Your eyes respond with a characteristic flicker called nystagmus, and you feel the room rotate.

How BPPV presents

The pattern is distinctive:

It is triggered by specific head positions. Rolling over in bed, lying down, sitting up, tipping your head back to look up or bending forward.
It is brief. True BPPV vertigo typically lasts under a minute, often only 10 to 30 seconds. It stops when you stop moving.
It is intense. People describe genuine room-spinning, not vagueness.
There is no hearing loss or tinnitus. If those are present, something else is going on.
Nausea is common. A lingering queasiness and wariness of movement often outlasts the spinning itself.

If your dizziness lasts for hours, is constant or has no positional trigger, BPPV is unlikely to be the whole story.

How it is diagnosed and treated

BPPV is diagnosed with a positional test, most commonly the Dix-Hallpike manoeuvre, which we use routinely in clinic. You are moved from sitting to lying with your head turned and slightly extended, and we watch your eyes for the nystagmus pattern that confirms which canal is involved. It reproduces the vertigo briefly, which is unpleasant for a few seconds but tells us exactly what we are dealing with.

Treatment is a repositioning manoeuvre, usually the Epley, which walks the crystals back out of the canal using a sequence of specific head positions. It takes a few minutes and we perform it in the same appointment as the diagnosis, so most people are treated on the day they come in.

The evidence behind it is excellent. Researchers combined the results of 27 separate trials involving more than 1,600 patients and found people treated with the Epley manoeuvre were around three times more likely to have their vertigo resolve than those who were not (Saishoji et al., 2023). It worked just as well in ordinary first-contact clinics as it did in specialist centres, and the researchers pointed out that treating BPPV promptly at that first visit spares a lot of people unnecessary referrals and hospital trips.

The American Academy of Otolaryngology clinical practice guideline reflects this. For uncomplicated BPPV it recommends repositioning manoeuvres as the treatment of choice, and specifically advises against routine imaging and against routine vestibular suppressant medication such as betahistine or antihistamines (Bhattacharyya et al., 2017). Medication tends to blunt the symptom without moving the crystal, and it can slow the brain’s natural compensation.

One thing worth knowing: it is common to feel a bit unsteady or foggy for several days after a successful manoeuvre, even once the true spinning has stopped. That residual dizziness usually settles on its own.

When the neck is the problem: cervicogenic dizziness

Your neck is a balance organ. This surprises most people.

The joints and deep muscles of the upper cervical spine are unusually dense in proprioceptors, the sensors that tell your brain where your head is in space. That information is combined with input from your inner ears and your eyes to produce a single coherent sense of position and movement.

When the upper neck is stiff, painful or has altered muscle tone, the signal it sends can conflict with what your eyes and inner ear are reporting. Your brain receives a mismatch, and the result is a sense of unsteadiness, floating or disorientation.

How cervicogenic dizziness presents

It looks quite different from BPPV:

The dizziness is unsteadiness rather than true spinning. Floating, swaying, drifting, feeling detached.
It is tied to your neck. It appears or worsens with neck movement, sustained postures or a flare of neck pain, and typically improves when the neck settles.
It lasts longer. Minutes to hours, not seconds.
Neck pain and stiffness are almost always present. Cervicogenic dizziness without neck symptoms is very unusual.
Headache is a frequent companion, often the kind that starts at the base of the skull.

It commonly follows whiplash or another neck injury, and it also shows up in people with long-standing neck pain from sustained desk posture.

It is a diagnosis of exclusion

There is no single test that confirms cervicogenic dizziness. It is identified by first ruling out inner ear, neurological and cardiovascular causes, and only then attributing the symptoms to the neck (Reiley et al., 2017). That is why the examination is the most valuable part of a first appointment.

The two also overlap more often than people expect. It is entirely possible to have BPPV and a stiff, aching neck at the same time, and working out which one is driving the dizziness determines what treatment should address first.

The encouraging part is that when the neck genuinely is the source, it responds well. Cervicogenic dizziness is one of the more treatable causes of persistent unsteadiness, and that is exactly why it is worth the time to identify it properly rather than assume it.

What the evidence says about treating it

Hands-on treatment of the upper neck helps, and the research supports it.

When researchers pooled the available trials in 2025, people who received manual therapy aimed at the upper neck came away noticeably less dizzy than those who did not, with the biggest gains in how intense the dizziness felt. The same analysis turned up something useful: treatment directed precisely at the upper neck joints worked better than general treatment spread across the whole neck (Carrasco-Uribarren et al., 2025). That is a good argument for a careful examination that pinpoints exactly which segments are involved rather than a broad approach. A second 2025 review reached the same conclusion, finding less dizziness and better neck movement after treatment (Casado-Sánchez et al., 2025).

Being straight about the limits: these were small studies that tracked people over weeks rather than years. That is not a sign the treatment does not work. It means nobody has yet run a trial large enough to pin down exactly how much it helps and how long the benefit holds. This is a young field of research rather than a discouraging one.

What we see in clinic is more encouraging than the research summaries suggest. Most people know within a few sessions whether their neck is the source, because when it is, the dizziness starts easing as the neck improves. You are not committing to months of treatment to find out.

Hands-on work is only half of it. Both research teams recommended pairing manual therapy with exercise, and that matches our experience. Treatment settles the irritated joints and restores movement, then targeted rehabilitation retrains the position sense that went wrong in the first place. That means straightforward exercises to sharpen your balance, improve the coordination between your eyes and head and rebuild deep neck strength. The combination is what makes the result stick.

Where the inner ear is involved as well, vestibular rehabilitation is on even firmer ground. A Cochrane review, the highest standard of evidence review there is, found it to be a safe and effective treatment (McDonnell and Hillier, 2015).

Red flags: when dizziness needs urgent attention

Most dizziness is benign. Some of it is not, and the difference can be time-critical. Seek emergency care if your dizziness comes with any of the following:

Sudden severe headache unlike any you have had before
Double vision, or difficulty moving your eyes
Slurred speech or difficulty finding words
Weakness, numbness or clumsiness in the face, arm or leg
Difficulty walking or a dramatic loss of balance
Sudden hearing loss in one ear
Chest pain, palpitations or fainting

These can indicate a stroke, a bleed or an arterial dissection affecting the balance centres in the brainstem and cerebellum. In an emergency department, clinicians use a bedside assessment called the HINTS exam to help separate a peripheral inner ear cause from a central one. If any part of your presentation points centrally, imaging and neurological review come before anything else.

Also worth a non-urgent medical review: dizziness that started after a new medication, dizziness with progressive hearing loss or one-sided tinnitus, and dizziness that is steadily getting worse rather than fluctuating.

What assessment looks like at our practice

When you come in with dizziness, the first job is working out which category you are in, not reaching for treatment.

That means taking a detailed history of your triggers, how long episodes last, what makes them better or worse and what else comes with them. It means positional testing such as Dix-Hallpike where the history suggests BPPV. It means a thorough examination of your upper neck, checking how well the joints move, how the muscles feel and how accurately you can sense your own head position. And it means a neurological screen and a check for the red flags above.

From there:

If it looks like BPPV, we confirm it with the Dix-Hallpike test and treat it with the Epley manoeuvre in the same visit. The response is usually quick, and many people notice a clear difference immediately. Where the picture is atypical, involves a canal that does not respond or keeps recurring, referral to an ENT or vestibular specialist is the right step.
If it looks like your neck, treatment combines hands-on work on the upper neck with exercises that retrain your balance and the coordination between your eyes and head, plus sorting out whatever is keeping the neck irritated in the first place, whether that is your desk setup, your training load or an old whiplash injury.
If it looks like neither, you get referred. Vestibular neuritis, Ménière’s disease, vestibular migraine, cardiovascular causes and medication effects all sit outside what we treat, and recognising them is part of the job.

When to get help

If your dizziness is brief, positional and spinning, there is a good chance it is BPPV and a good chance it can be resolved quickly. If it is a persistent unsteadiness that travels with neck pain and stiffness, your neck is worth investigating properly.

Either way, dizziness that is affecting your driving, your work or your confidence on your feet is worth assessing rather than waiting out. At our Sandton practice we can work through the differential, treat what falls within our scope and refer where it does not.

Get in touch or book an appointment.

References

DIZZINESS AND VERTIGO: IS IT YOUR NECK OR YOUR INNER EAR?