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Head Tilts and Eye-Misalignment – The Ocular Tilt Reaction

Patients with dizziness can present with abnormalities in their head and eye positions. A classic example of this is called an ocular tilt reaction.⁣

An ocular tilt reaction occurs when damage occurs to some of the pathways that affect the brain stem or the vestibular system. These pathways help to keep your eyes level with the horizon and form the basis of the righting reflex.⁣

The righting reflex ensures that you see the world level with the horizon even when you tilt your head to the side. Whenever you tilt your head to the side, your eyes roll to compensate. This is why you can tilt your head sideways, and you still perceive the world as straight.⁣

When there is an injury to the vestibular system (otoliths) or something affects the eye movement pathways in the brainstem, this ability can be broken.⁣

This results in the patient having eyes rotating abnormally and can cause an abnormal tilt of the head.⁣

Clinicians can use knowledge of these pathways to pinpoint where in the brainstem or vestibular pathway that damage may have occurred. It can also help them differentiate between a strabismus from a cranial nerve 4 lesion or a vestibular/brainstem problem.⁣



This is important to know because these pathological tilt reactions are an important sign of a peripheral or central cause of dizziness/imbalance that may look like a cervical spine/alignment issue.⁣

We have to be knowledgeable about some of these pathways because these are cases in which we may not be able to fix someone’s head tilt from something like an upper cervical adjustment because the neural pathways allowing for a normal righting reflex just aren’t there anymore so we shouldn’t chase after it.⁣

It may allow us to provide compensation mechanisms to help improve balance and stability.⁣