Cervicogenic Drivers in Chronic Concussion — Why ~54% of PPCS Patients Need Cervical Assessment [2026]

Concussion biomechanics involve linear and rotational acceleration of the head. The neck transmits and absorbs those forces. The same impact that produces brain injury produces cervical soft-tissue strain, facet joint irritation, and (in higher-velocity injuries) ligamentous injury.

This is anatomically inevitable. Yet at acute presentation:

• Clinical attention focuses on the head — SCAT6, GCS, red flag screening
• The patient's primary complaint is usually headache, nausea, dizziness — none of which automatically point the clinician toward the cervical spine
• If the cervical exam happens at all, it's often a brief range-of-motion check, not a structured workup

The result is that the cervical contribution is identified only later — usually when the patient hasn't resolved and someone with a chronic-case framework finally looks for it.

Cervicogenic dizziness is dizziness arising from afferent input mismatch — proprioceptive signals from injured cervical structures conflict with vestibular and visual signals, producing the subjective sensation of imbalance or vertigo.

Clinical features that differentiate it from vestibular dizziness:

• Provoked by neck position/movement rather than head movement specifically
• No typical nystagmus pattern on positional testing (vs BPPV which has stereotyped patterns)
• Associated with cervical pain or restriction
• Improves with cervical treatment (manual therapy, mobilisation) — diagnostic-therapeutic test

Targeted tests:

• Neck torsion test (Norré) — patient sitting, head held stationary, body rotated. If symptoms reproduce, cervicogenic involvement is likely.
• Cervical relocation test — patient closes eyes, head rotated to target, asked to return to neutral. Increased error suggests cervical proprioceptive dysfunction.

Note: cervicogenic dizziness and vestibular dysfunction frequently coexist in PPCS. Identifying the cervical contribution doesn't rule out the need for vestibular workup — see our vestibulo-ocular workup article.

Cervicogenic headache is unilateral headache referred from cervical structures, most commonly the upper cervical joints (C0-C3) and sub-occipital musculature.

Diagnostic features:

• Unilateral (almost always) and side-locked (stays on the same side over time)
• Reproduced by cervical movement or palpation of upper cervical structures
• Restricted cervical ROM, particularly in rotation to the symptomatic side
• Absence of migraine-typical features (photophobia, phonophobia, aura) — though overlap can occur
• May radiate to ipsilateral forehead, eye, or temple

Differential with migraine, tension-type headache, and post-traumatic headache is important — see the full PPCS workup for the wider headache assessment framework.

• Active cervical range of motion, quantified. Flexion, extension, lateral flexion (both sides), rotation (both sides). Compare to expected for age. Pain provocation pattern at end-range.
• Cervical flexor endurance test — supine, head retracted and lifted, hold time recorded. Reduced endurance is a near-universal finding post-whiplash and is highly trainable.
• Passive segmental assessment — particularly upper cervical (C0-C3 joints). Assess passive intervertebral motion, end-feel, pain reproduction.
• Sub-occipital muscle palpation — trigger points, tone, tenderness. Sub-occipital + scalenes + sternocleidomastoid are the consistent involvement pattern.
• Neurological screen — myotomes, dermatomes, reflexes — to rule out radiculopathy or other red flags.
• Provocation tests — neck torsion (described above), upper cervical flexion-rotation test for C1-C2 mobility.

The cervical workup must always start with red-flag exclusion in any post-trauma presentation. Refer urgently for imaging if any of:

• Persistent neurological deficit (motor, sensory, reflex)
• Bladder/bowel symptoms or saddle anaesthesia (suspect cord/cauda equina)
• Severe persistent pain unresponsive to first-line management
• High-energy mechanism (motor vehicle, fall from height, sport with significant force) — apply Canadian C-Spine Rule
• Age >65 with any cervical complaint after fall

If red flags are absent and the patient is in the chronic-symptom window, the cervical workup is safe to proceed.

Cervical contribution to PPCS responds well to multi-modal treatment:

• Manual therapy — joint mobilisation (upper + lower cervical), soft tissue work for sub-occipitals + scalenes
• Deep neck flexor strengthening — craniocervical flexion exercise (Jull protocol). Build endurance progressively.
• Postural retraining — particularly relevant for screen-heavy occupational profiles
• Sensorimotor retraining — cervical relocation training, gaze stability with cervical input
• Patient education — explain the cervical contribution; patients often have only been told they have a “concussion that won't resolve” and don't know cervical involvement is the missing piece

Expect noticeable improvement within 4-6 sessions if cervical contribution is a primary driver. If no improvement, the cervical is contributing but not primary — escalate to the broader PPCS workup.