Specialist article: head balance
Wobbly head?When the head finds no secure hold
Your head feels heavy or unsteady, there is clicking in your upper neck, and the report says “unstable upper cervical joints”? Here you will find out what lies behind the so-called wobbly head, how reliable the diagnosis is, what studies show about surgical fusion and why we train head balance together with breathing and swallowing.
Does this sound familiar?
Your head no longer sits securely, and nobody can find the reason?
What applies to you?
Tap whatever applies to you.
If several points apply, it is worth taking a close look at how your head is held. The stability of the upper cervical joints comes from ligaments, muscles and above all from the pattern with which the nervous system uses these muscles. This pattern can be trained.
What unstable means hereWhat studies show about fusionThe key points at a glance
- “Wobbly head” is not a medical term. It usually does not mean visible wobbling, but the feeling that the head has no secure hold. Visible trembling should be investigated neurologically.
- The upper cervical joints account for a good half of head rotation and have little bony guidance. Their stability depends on muscles and on the control that uses these muscles. In our view, if the control pattern is disturbed, the holding apparatus steps in.
- Without clear findings, the diagnosis of upper cervical instability is uncertain, and the evidence on fusion is thin. We therefore work on the pattern of breathing, swallowing and head balance, which can be trained.
Video
Unstable upper cervical joints and a wobbly head: what lies behind it
Das Video lädt erst nach dem Klick. Dann werden Daten an YouTube (Google) übertragen.
Term
“Wobbly head”: what it means
People who search for “wobbly head” rarely mean the same thing. That is why it is worth taking the term apart first.
You won’t find the “wobbly head” in any medical textbook, and yet everyone immediately understands what is meant. Many of those affected do not describe a head that visibly wobbles back and forth. They describe a head that feels heavy, unsteady or poorly supported. In medical reports this is then called upper cervical instability, unstable upper cervical joints or unstable cervical spine, meaning an unstable cervical spine in its upper section.
Feeling that the head does not sit securely
- Feeling of heaviness, the head has to be “held”
- Clicking or grinding in the upper neck
- Pain in the neck and back of the head, often with jaw tension
- Brief unsteadiness during quick head movements
Visible trembling or nodding of the head
- The head moves rhythmically without you wanting it to
- Others can see it, often more strongly under tension
- Can be part of a tremor or a dystonia
- Should be investigated neurologically
In everyday language, both are called a “wobbly head”. If your head visibly and involuntarily trembles or nods, have it examined neurologically.
Dr. Klaus Berndsen therefore describes the wobbly head as a dysbalanced head. This shows throughout the whole body: the shoulders drop forward, the transition to the back of the head is more sharply angled, and below this follow a hollow back and a forward-pushed pelvis. So the question is less which ligament is too weak than why the head no longer stays in balance by itself.
Anatomy
Two small joints carry the whole head
The upper cervical joints are the most mobile joints of the spine. That is exactly what makes them dependent on guidance.
The head sits on two joints. The upper one connects the occiput with the first cervical vertebra, the atlas, and mainly carries nodding. The lower one connects the atlas with the second cervical vertebra, the axis, and is responsible for rotation. Together they are called the upper cervical joints, and the region is known as the craniocervical junction.
This section is secured by ligaments, because the shape of the bones provides little hold. The alar ligaments (ligamenta alaria) limit rotation, and the transverse ligament of the atlas holds the dens of the axis in place. Muscles take care of the rest.
of total head rotation was performed by the joint between atlas and axis, on average 37.9 of 72.4 degrees, measured by CT in 20 healthy adults1
is roughly what an adult’s head weighs. This weight balances on two joints that together are only a few centimetres high
per gram of muscle were counted by a research group in the obliquus capitis inferior, one of the short neck muscles, studied in foetuses2
The upper cervical joints are not built on bone. They are built on control.High mobility with little bony guidance means that stability comes from soft tissue and muscle work, and this muscle work is set by the nervous system.
Chain of cause and effect
In our view, unstable means: the control pattern is disturbed
The short neck muscles below the occiput are less power motors than sensors. That changes how we look at instability.
Muscle spindles are sensors in the muscle fibre that continuously report how much a muscle is being stretched. In the short neck muscles they are very densely packed2. Through them, the brain learns where the head is at any given moment. A research group in Paris showed how important this is. After an active head movement, 30 people with neck pain found their way back to their starting position measurably less accurately than 30 healthy people3.
The division of labour between the muscles also shifts. An Australian group recorded directly from the deep flexors at the front of the cervical spine in ten people each with and without chronic neck pain. During the task of nodding very finely, the deep muscles in the pain group worked less. The large sternocleidomastoid and the anterior scalene muscle, on the other hand, showed a tendency towards more activity, although this was not statistically significant4. The deep layer works less, and the surface steps in.
The control pattern deviates
Mouth breathing, a low-lying tongue and a head that drifts forward change the starting position. The fine balance from the short neck muscles loses its reference point.
The holding apparatus compensates
Trapezius, sternocleidomastoid and levator scapulae take over what fine control can no longer do. The nervous system stores this substitute solution as the preferred pattern.
The structure takes the load
Ligaments and joint capsules are under constant tension, and more shear forces act in the upper neck. The tissue adapts, and the upper cervical joints are described as “loose” or “unstable”.
Complaints arise
Neck pain and headache, jaw tension, unsteadiness during head movements, the feeling of a wobbly head. When and how strongly depends on the extent and duration of the compensation and on age.
Lie on your back with your head flat. Nod very slightly, as if saying “yes”, without lifting your head. What happens?
Outer system and inner system
The large muscles hold, the small ones balance
In the Cranio-Cervical Functional Model, CCFM for short, Klaus and Sabine Berndsen distinguish two systems that carry the head.
The outer system consists of the large, superficial muscles such as the trapezius and sternocleidomastoid. They secure the head against gravity and perform gross movements. Beneath it lies the inner system. This includes the short muscles below the occiput and the muscles of the tongue, hyoid bone and floor of the mouth, which secure the head from the front.
The outer system holds, the inner system balances. In our view, the large neck muscles are strong enough in many people. What is missing is the fine adjustment.
Like a mast with guy lines
A mast stays upright when its lines pull evenly on all sides. If the front lines go slack, the rear ones have to pull harder so that the mast does not tip over. The mast then stands, but under constant tension. We see the head in a similar way. If the balance from the front, from the tongue, hyoid bone and floor of the mouth, is missing, the neck works as a permanent holder.
That is why, in our view, it is not enough to strengthen the neck. Anyone who trains the posterior muscles is training the system that is already overloaded. Isolated strength training of individual muscles, such as the tongue against resistance, trains a partial performance. The tongue pressure increases, but what happens to the swallowing process itself remained inconsistent in a review13. Swallowing requires a sequence, not a strength value.
In our view, strength training therefore usually does not reset the interplay of breathing, swallowing and head balance. We describe in detail how the tongue, hyoid bone and floor of the mouth are connected with the neck in the article Neck pain and back pain. Where the tongue has its reference point in everyday life is explained in the article on the tongue reference position.
Jaw and head
Jaw and head move together
The upper cervical joints do not work alone. They are linked with the jaw, tongue and swallowing into one sequence.
At Umeå University, researchers simultaneously recorded the movements of the lower jaw and head in twelve healthy young adults. Every jaw movement was accompanied by a head movement, and the head movement usually began before the jaw movement5. The authors concluded that jaw and neck muscles are activated together, with simultaneous movements in the jaw joint, the upper cervical joint and the cervical spine.
The head adjusts first
Before the jaw opens, the head extends slightly. The nervous system sets the frame of reference before the movement starts5.
The neck changes chewing
Twelve people after a whiplash injury of the cervical spine moved their jaw and head less far and with altered timing compared with healthy people6.
Swallowing is part of it
Many hundreds to a thousand times a day, the hyoid bone rises when you swallow, and the muscles at the front of the neck work along with it. In our view, swallowing is therefore also work for head balance.
Anyone who looks at the upper cervical joints without the jaw, tongue and swallowing sees only part of the system. You can read why jaw and neck complaints so often occur together in the article on TMD, and how the swallowing pattern is built up in the article on swallowing and swallowing disorders.
Diagnostics
How reliable is the diagnosis of upper cervical instability?
Instability of the upper cervical joints sounds like a clear finding. The research shows how difficult it actually is to pin down.
For the upper cervical spine there are a number of manual tests that practitioners use to check for instability. A review from the Netherlands and Belgium found only five studies that could be evaluated. Seven tests gave a positive result sufficiently rarely in people without instability, but missed an existing instability at varying rates, and the ranges of uncertainty were wide7. Imaging does not automatically provide clarity either.
of people with persistent complaints after a whiplash injury showed abnormal signals in at least one alar ligament on MRI8
of the comparison group without neck pain and without an accident showed the same abnormalities, in the same study with 173 people8
from 16 papers were found by a review on upper cervical instability in connective tissue weakness. No paper reached a high level of evidence9
The authors of the MRI study therefore consider the diagnostic value of such ligament signals questionable8. The review on Ehlers-Danlos syndrome found ten different measures and no consensus on the point at which instability is present. It recommends surgical fixation only when the instability is clearly visible on imaging and matches the complaints9.
A finding describes what a tissue looks like. Whether it explains the complaints is a second question. So if you are given a diagnosis of upper cervical instability, ask what it was based on, whether it was visible on functional imaging and whether it matches your complaints.
Surgery
Fusing before the cause has been clarified?
With unclear complaints in the upper neck, the word fusion sometimes comes up early. Plates, screws and rods then fix the uppermost vertebrae to the back of the skull.
There are clear reasons for a fusion: a fracture, a torn ligament after an accident, inflammatory rheumatism with a loosened atlas, a tumour or loss of function of nerves and spinal cord. We do not question that. It is a different matter when ligaments and connective tissue are judged to be “too weak” without anyone asking why they became weak.
from 34 studies were evaluated in a review on fusion between the back of the skull and the cervical spine. No study was above the lowest evidence class IV10
adverse events after surgery occurred even with the technique with the best results, screws with rods10
of those operated on developed new nerve complaints in the adjacent segment after a fusion lower down the cervical spine, around a quarter over ten years11
The last figure comes from fusions below the upper cervical joints, and the authors attribute the new complaints more to progressive wear11. Regardless of this, mechanically speaking: a fusion ends movement in one segment, but the load does not disappear. In the case of the upper cervical joints, there is the added factor that a good half of head rotation takes place precisely there1.
A fusion answers the question of how a segment can be held. It does not answer why it was no longer being held.If the finding is unclear, in our view the control of breathing, swallowing and head balance should be trained first before a fusion is considered. Whether an intervention is necessary for you is something to discuss with your treating practice.
Safety
When to have a wobbly head checked by a doctor
In our view, many complaints in the upper neck are functional. However, some signs suggest that an examination is needed first.
After an accident or fall
The complaints began after a rear-end collision, a fall onto the head or a sports accident.
Tingling or weakness
Numbness, tingling or loss of strength in the arms, hands or legs, an unsteady gait or problems with fine motor skills.
Deficits in the head area
Double vision, speech or swallowing disorders, sudden falls without loss of consciousness, or dizziness when turning the head that occurs together with such signs.
Known underlying condition
Inflammatory rheumatism, Down syndrome, a connective tissue disorder such as Ehlers-Danlos syndrome, or previous surgery on the cervical spine.
Visible tremor
The head trembles or nods involuntarily. This needs a neurological examination.
New severe pain
New, intense pain in the neck or back of the head, especially with fever, neck stiffness or constant pain at night.
If you wear a neck collar or are receiving medical or physiotherapy treatment, do not stop any of it on your own and discuss changes with your practice. Training the basic functions can be combined with treatment.
Training
Training head balance: control instead of strength
If, in our view, instability is as a rule a control problem, training has to start with control.
A randomised study from Brisbane shows that fine control of the neck can be trained. 64 women with persistent neck pain practised for six weeks either specifically relocating the head position or fine nodding from the upper cervical joints. In both groups, they afterwards returned more accurately to the starting position, and pain and impairment decreased12. The study does not examine the FaceFormer, but it supports the principle that control can be trained.
In FaceFormer training, every exercise begins with head alignment. Imagine someone gently pulling you upwards by a thread at the back of your head. The neck lengthens slightly, the chin drops a little, the shoulders follow by themselves.
The natural curve of the cervical spine is preserved. It should be able to give, only the bend at the transition to the back of the head becomes smaller.
In the basic exercise, the FaceFormer sits in the oral vestibule, behind the lips and in front of the teeth. The tip of the tongue rests at the reference point behind the upper incisors, and you breathe through your nose. You press the lip wedge together for six seconds, bite down briefly with your back teeth and swallow.
When you swallow, the negative pressure draws the tongue to the palate, and the muscles of the floor of the mouth and the front of the neck work along in coordination. In this way you practise breathing, swallowing and head balance in one sequence.
- From day 1
Head alignment and basic exercise
A few minutes three times a day with the FaceFormer ZERO. The free FaceFormer app guides you.
- From around week 3
Pull exercise and night
The pull exercise is added. At night you wear the FaceFormer ZERO as soon as you have the basic exercise down.
- After a few weeks
Switching to the ONE
During the day, you train with the FaceFormer ONE. It is the same size and shape as the ZERO, just made of firmer material.
- Later
Head balance rotation
With the head balance rotation you slowly turn your head to the side while lip closure, tongue position and nasal breathing are maintained. Ideally in consultation with a practice.
- Over months
The pattern runs by itself
The exercise manual allows six to twelve months until the new sequences run without thinking, followed by maintenance training.
Being honest about the research: there is no controlled study on the effect of FaceFormer training on the upper cervical joints. Our own investigations exist on posture, not on the upper cervical joints themselves. We explain what they show and what they do not on the page Studies and science. The absence of a study does not mean that the connection does not exist. It means that it has not been tested.
A stored pattern is changed by training it.In our understanding, there is no equivalent alternative to training the basic functions, because with this logic we see no other way of changing a stored pattern than training it.
Everyday life
In everyday life, balance your head instead of holding it
Lengthen instead of pulling back
Do not pull your chin back or squeeze your shoulders together. Think of the thread at the back of your head, and the rest follows.
Lips closed, tongue up, nose open
The lips rest loosely together, the tip of the tongue at the reference point, and the air takes the route through the nose. This gives the head support from the front.
Teeth apart
Except when chewing and swallowing, the teeth are slightly apart. Clenching tenses the neck along with it.
Screen at eye level
Adjust your screen and seat so that your head balances over your body and does not drift forwards.
Turning calmly
Turn your head slowly and deliberately instead of jerking it to look over your shoulder. Slow movements give the short neck muscles time to measure.
Do not stop prescribed treatment on your own
Discuss a neck collar, physiotherapy or medication with your practice. The training can be combined with them.
The upper neck is also a junction for nerves that act far beyond the neck. You can read more about the rest nerve in the article on the vagus nerve, and about ear noises related to the jaw and neck in the article on tinnitus.
Questions
Frequently asked
What is a wobbly head?
“Wobbly head” is an everyday expression, not a medical term. It usually refers to the feeling that the head has no secure hold, often with neck pain, clicking in the upper neck and unsteadiness during head movements. In medical reports this is called upper cervical instability or an unstable cervical spine. A visible, involuntary trembling of the head is something else and should be investigated neurologically.
What are the symptoms of unstable upper cervical joints?
Commonly mentioned are pain in the neck and back of the head, a feeling of heaviness in the head, clicking when turning, jaw tension and brief unsteadiness during quick movements. These symptoms also occur without any demonstrable instability. Tingling, weakness, double vision or swallowing difficulties should be investigated promptly by a doctor.
Can upper cervical instability be seen on an MRI?
Not reliably. In a Norwegian study with 173 people, 49 % of those who had had whiplash showed abnormal signals in the alar ligaments, but so did 40 % of the control subjects without symptoms and without an accident. The authors consider the diagnostic value of such findings questionable. Images taken during movement that match the symptoms are more meaningful.
Does an unstable cervical spine need surgery?
Only with clear findings, for example after a fracture, with torn ligaments, inflammatory rheumatism, tumours or deficits of the nerves and spinal cord. Without clear instability on X-ray, surgical reviews also recommend restraint. Whether an operation is an option for you is something you discuss with your treating practice.
Does strength training for the neck help with a wobbly head?
In our view, only to a limited extent. In many people the large neck muscles are strong enough and, with a wobbly head, are already working as permanent holders anyway. What is missing is the fine control from the short neck muscles and the balance from the front via the tongue, hyoid bone and floor of the mouth. Studies show that this fine control can be improved through targeted exercises.
Can you stabilise unstable upper cervical joints yourself?
You can train the pattern your nervous system uses to secure the upper cervical joints. In FaceFormer training you practise head alignment, lip closure, tongue reference position, nasal breathing and swallowing in one sequence. The training creates the conditions under which symptoms can improve. If there are warning signs, have them checked by a doctor first.
What does the jaw have to do with the upper cervical joints?
Jaw and head move together. The head adjusts even before the jaw opens, and after whiplash chewing is altered too. That is why many people with symptoms in the upper neck also have jaw problems.
When should I see a doctor about a wobbly head?
After an accident or fall, with numbness, tingling or weakness in the arms or legs, with double vision, speech or swallowing difficulties, with sudden falls, with a visible trembling of the head and with known underlying conditions such as inflammatory rheumatism or a connective tissue disorder.
More articles from the knowledge section
Where to go next
Sources
- Zhai X, Kang J, Chen X, Dong J, Qiu XW, Ding XA, Liu J, He XJ (2019). In vivo measurement of three-dimensional motion of the upper cervical spine using CT three-dimensional reconstruction [Chinese]. Zhongguo Gu Shang 32(7):658-665. PMID 31382726. Source
- Kulkarni V, Chandy MJ, Babu KS (2001). Quantitative study of muscle spindles in suboccipital muscles of human foetuses. Neurology India 49(4):355-359. PMID 11799407. Source
- Revel M, Andre-Deshays C, Minguet M (1991). Cervicocephalic kinesthetic sensibility in patients with cervical pain. Archives of Physical Medicine and Rehabilitation 72(5):288-291. PMID 2009044. Source
- Falla DL, Jull GA, Hodges PW (2004). Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test. Spine 29(19):2108-2114. PMID 15454700. Source
- Eriksson PO, Häggman-Henrikson B, Nordh E, Zafar H (2000). Co-ordinated mandibular and head-neck movements during rhythmic jaw activities in man. Journal of Dental Research 79(6):1378-1384. PMID 10890716. Source
- Häggman-Henrikson B, Zafar H, Eriksson PO (2002). Disturbed jaw behavior in whiplash-associated disorders during rhythmic jaw movements. Journal of Dental Research 81(11):747-751. PMID 12407088. Source
- Hutting N, Scholten-Peeters GG, Vijverman V, Keesenberg MD, Verhagen AP (2013). Diagnostic accuracy of upper cervical spine instability tests: a systematic review. Physical Therapy 93(12):1686-1695. PMID 23886844. Source
- Myran R, Kvistad KA, Nygaard OP, Andresen H, Folvik M, Zwart JA (2008). Magnetic resonance imaging assessment of the alar ligaments in whiplash injuries: a case-control study. Spine 33(18):2012-2016. PMID 18708935. Source
- Lohkamp LN, Marathe N, Fehlings MG (2022). Craniocervical Instability in Ehlers-Danlos Syndrome: A Systematic Review of Diagnostic and Surgical Treatment Criteria. Global Spine Journal 12(8):1862-1871. PMID 35195459. Source
- Winegar CD, Lawrence JP, Friel BC, Fernandez C, Hong J, Maltenfort M, Anderson PA, Vaccaro AR (2010). A systematic review of occipital cervical fusion: techniques and outcomes. Journal of Neurosurgery: Spine 13(1):5-16. PMID 20594011. Source
- Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH (1999). Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. Journal of Bone and Joint Surgery (American) 81(4):519-528. PMID 10225797. Source
- Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B (2007). Retraining cervical joint position sense: the effect of two exercise regimes. Journal of Orthopaedic Research 25(3):404-412. PMID 17143898. Source
- Smaoui S, Langridge A, Steele CM (2020). The effect of lingual resistance training interventions on adult swallow function: a systematic review. Dysphagia 35(5):745-761. PMID 31612288. Source
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FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
