Published August 19, 2019 By Adam Lowenstein

Dizziness, imbalance, and disorientation in headache and neck pain patients

One of the most frequent questions posted to facebook on migraine headaches and tension headaches forums involves some aspect of dizziness, imbalance, and disorientation.  While headache patients may be used to pain, waking up dizzy or having balance issues with or without pain can be alarming to those who suffer from migraines or tension headaches.  To those of us who care for these patients, we have been relieved to finally find some scientific reasoning that may explain these issues.

First let’s get through some terms:

– Vertigo is a sudden onset of a sensation of spinning.
– Dizziness refers to an abnormality of stability or balance.
– Imbalance is a difficulty keeping one’s balance particularly when upright.

Vertigo, dizziness, and imbalance can all be associated with headache and can be from different causes, but the data is accumulating correlating to a direct relationship between the occipital nerves (of the back of the neck and head) and this disorienting problem.  Patients who have irritation and/or inflammation of these nerves may have a reason to be dizzy.  And this dizziness can come with or without accompanying pain.

Second, let’s have a look at the anatomy of balance and dizziness.  Many may know that the sense of orientation that we normally experience begins in the ear, and the inner ear to be specific.  There are two aspects of the inner ear that are involved in balance, and they are cumulatively referred to as the vestibular system.  The anatomy of this part of the inner ear involves tubules or canals oriented in 3 different directions corresponding with the 3 dimensions that you can move in.  These canals are filled with fluid, and as you move the flow of these fluids create signals that go to the brain to indicate your position in your space.  Additionally, there are crystals made of calcium carbonate that are found in a spot called the utricle of the ear, and the motion/pressure from these crystals on the tissue of the utricle signals your muscles to help stabilize you with respect to acceleration and deceleration in motion, such as when you are moving or when you are in a car.

There are several things that can go badly in the ear itself, such as benign positional vertigo or Meniere’s Disease.  These conditions involve problems in the flow of the fluid of the inner ear or the position of the crystals that are supposed to be settled in the utricle.  It is important to remember that just as you have two ears, you have two vestibular systems that work together to orient your position and your response to motion.  An issue on one side of your head, in one ear can create a confusion in your brain, when the opposite normal ear’s signals don’t mesh correctly with what is expected from the problematic ear.

Now let’s move on to the next part of the management of balance, which involves the nerves that travel from the inner ear to the brain.  The eighth cranial nerve, called the vestibulocochlear nerve, brings signals from the ear to the brain.  This nerve sends fibers to several portions of the brain, including the vestibular nucleus of the brain stem as well as the cerebellum.  Sorry again for the technical anatomy terms, but this will be important later.  The important part to understand here is that the cerebellum is the portion of the brain that coordinates movement, and movement, balance, and orientation all need to be coordinated in order to maintain an equilibrium and avoid imbalance and dizziness.

The next anatomical term that we need to understand is called the dura.  The dura of the brain is the coating of the brain, a tissue lining that surrounds the brain and has sensory (feeling) fibers that are part of the pain of headaches of many types.  Similar to how skin surrounds and contains the body, the dura surrounds and contains the brain, and just as painful sensations on your skin cause discomfort, painful sensations at the dura cause headache pain.

If I haven’t lost you with technical jargon yet, the next part of the understanding between migraine, tension headache, occipital neuralgia, and dizziness involves the occipital nerves.  These nerves as many readers know have been linked to the cause of many of these headache syndromes.These nerves as many readers know have been linked to the cause of many of these headache syndromes.  Inflammation and irritation of these nerves have been shown to provide the distress signals to the brain that cause the headaches of many migraines, tension headaches, and of course occipital neuralgia.  These occipital nerves are sensory nerves, detecting sensation, stretching, and pain.

Now here is where it gets interesting…. Recent studies have shown that there are fibers of the occipital nerves that surprisingly travel from the back of the head and neck to the dura of the brain, and additionally to the dura of the cerebellum which you will remember from the paragraphs above are responsible for coordination of motion and balance.[1]  Now that we know that there is an intermingling of nerve fibers from the occipital nerves and the dura, we can easily understand how irritation of the occipital nerves is perceived as headache pain.  It is easy then to take the next step in understanding that as these fibers intermingle with the dura or lining of the cerebellum, the irritation of the occipital nerves can create distress in this part of the brain which we know coordinates motion and balance.  We can see how irritation of these peripheral occipital nerves found in the muscles of the neck and in the back of the head may be causing not only headache pain, but dizziness, and balance issues as well.

So what can we do about this?  How can we prevent both the pain as well as the dizziness found in migraine headaches, chronic daily headaches, tension headaches, and the like?  By preventing the occipital nerves from experiencing irritation, we can prevent the distress signals that in these nerves that cause both pain and dizziness and imbalance.  Nerve decompression surgery, also called migraine surgery, is an outpatient procedure in which the tissues that compress and irritate the occipital nerves are released such that the nerves lie comfortably in a non-irritated fashion, and the distress signals mentioned above are prevented from happening in the first place. 

While I apologize for the rather technical explanation here, it is important for patients who experience different symptoms to understand where and how their complaints may be arising.  The complexity of the human body, particularly the nerves and brain, is an amazing thing when functioning properly.  In patients with tension in their neck, or tight muscles, or patients who have blood vessels, connective tissue, or scar tissue putting pressure on their occipital nerves, this miraculous complexity can cause pain and dizziness as well as other symptoms that can be problematic and debilitating.  We are fortunate that advanced studies are now showing how migraine surgery or nerve decompression surgery can improve the lives of these patients.[2]

To see an example of how a patient with balance issues benefitted from migraine surgery, look for Christine’s discussion of her surgery toward the bottom this page here.  

To find out more about migraine surgery (nerve decompression surgery) click here, and find information about the work up and expectations for this highly successful outpatient procedure throughout our website.  To see if we can help you or your loved one, please contact us at 805-969-9004.

Learn More About Migraine Surgery from Dr. Lowenstein


1)Noseda R, Melo-Carmillo A, Nir R-R, Strassman A, Burstein R (2019) Non-trigeminal nociceptive innervation of the posterior dura: implication to occipital headache. J Neuroscience

2)Blake, Pamela, and Rami Burstein. “Emerging Evidence of Occipital Nerve Compression in Unremitting Head and Neck Pain.” The Journal of Headache and Pain, vol. 20, no. 1, 2019, pp. 76–83., doi:10.1186/s10194-019-1023-y.

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