Dizziness following concussion is one of the most complex presentations in clinical practice — not because the mechanisms are mysterious, but because multiple systems are almost always involved simultaneously. A skilled clinician untangles them and treats each one in the right order.
The Five Mechanisms
- •Peripheral vestibular (BPPV) — up to 28% of concussion cases; most treatable component, resolve first
- •Central vestibular disruption — brainstem and vestibulo-cerebellum vulnerable to concussive forces
- •Cervicogenic — whiplash mechanism injures upper cervical mechanoreceptors
- •Autonomic dysregulation — orthostatic intolerance with exertion and position changes
- •Visuo-vestibular mismatch and anxiety — motion sensitivity, busy environments, avoidance cycle
Six-Stage Assessment
- •Stage 1 — Subjective history (mechanism, trajectory, symptom triggers)
- •Stage 2 — Oculomotor screening (smooth pursuit, saccades, vergence, VOR cancellation, nystagmus)
- •Stage 3 — BPPV screen (Dix-Hallpike and Supine Roll Test for every patient)
- •Stage 4 — Cervical spine (ROM, segmental, deep cervical flexors, SPNT)
- •Stage 5 — Balance and gait (BESS, tandem, dual-task)
- •Stage 6 — Autonomic screen (orthostatic vitals, Buffalo Concussion Treadmill Test if indicated)
Treatment Phases — Order Matters
Phase 1 (weeks 1–2): resolve BPPV and gentle cervical mobilisation. Phase 2 (weeks 2–6): graduated oculomotor and gaze stabilisation (VOR x1/x2, smooth pursuit/saccades, vergence). Phase 3 (weeks 4–10): balance, dual-task, and real-world function. Phase 4: graduated aerobic conditioning and return to activity.
Dosing principle: Post-concussion VRT should provoke mild symptoms (2–4/10) that resolve within 30 minutes. Persistent provocation means the dose was too high — reduce intensity, not frequency.
Prognosis
Most uncomplicated concussions resolve in 10–14 days. Post-concussion syndrome occurs in 15–30%. BPPV component: 1–3 sessions. Cervicogenic component: 6–12 sessions. Central vestibular dysfunction: 8–16 sessions, sometimes 3–6 months in complex cases.
Want to master this in practice?
The Dizziness Decoded series gives you a complete, hands-on framework for assessing and treating vestibular and dizziness conditions. Small groups of 12. Real practice. Real confidence.