Can a Neck Adjustment Cause a Stroke?

One of the most common concerns people have about neck adjustments is whether they can cause a stroke. The concern relates to a rare condition called cervical artery dissection (CeAD), where a tear develops within the wall of an artery in the neck. In some cases, this can lead to an ischaemic stroke.

Current evidence does not support describing neck adjustment as either completely risk-free or inherently dangerous. To understand the risk properly, we need to look at several different types of evidence — not just reports of events occurring after treatment.

1. What Do Population Studies Tell Us?

Cassidy et al. (2008) found that vertebrobasilar stroke was associated with recent visits to both chiropractors and primary-care physicians. One possible explanation is that an arterial dissection may already be developing before a person seeks treatment. Neck pain or headache can be early symptoms, prompting some patients to visit a chiropractor or doctor before the vascular problem is recognised.

Chaibi and Russell (2019) described this as a “chicken-and-egg” problem: did the treatment contribute to the dissection, or was the dissection already developing and causing the neck pain or headache that led the person to seek care?

More recently, Whedon et al. (2025) analysed 291,604 older adults with new-onset neck pain and found no statistically significant difference in stroke or vertebrobasilar insufficiency between chiropractic care and primary medical care alone.

The American Heart Association/American Stroke Association (Biller et al. , 2014) has also acknowledged the reported association while noting the difficulty in determining whether the association reflects an already-developing dissection, treatment-related mechanical factors or other causes.

Church et al. (2016) similarly reported a small association but rated the overall evidence as very low quality due to the potential for bias and confounding.

Although a small treatment-related risk cannot be completely excluded, current population studies have not established that neck adjustment causes CeAD or stroke.

2. Does a Neck Adjustment Place Excessive Strain on the Vertebral Artery?

The vertebral arteries naturally move and change length as we turn, bend and extend the neck, particularly around the V3 segment.

Biomechanical studies by Herzog et al. (2012) and Gorrell et al. (2022) found that vertebral artery elongation during neck adjustment was generally within or below the ranges produced during normal or passive neck movement, and well below experimentally measured failure thresholds. However, laboratory studies cannot fully reproduce every clinical situation, particularly when an artery may be affected by underlying vascular pathology, anatomical variation or an already-developing dissection.

Current biomechanical evidence does not suggest that a typical neck adjustment routinely overstretches the vertebral artery, but it cannot tell us how every potentially vulnerable artery will respond.

3. Does a Neck Adjustment Compromise Blood Flow to the Brain?

Kranenburg et al. (2019) reviewed 31 studies examining arterial blood flow during different head and neck positions and movements. Some studies reported changes during maximal neck rotation or combined rotation and extension. However, only three studies specifically examined high-velocity thrust positioning or movement, and none reported significant haemodynamic changes.

Moser et al. (2019) used MRI to investigate vertebral artery and cerebral haemodynamics associated with neck adjustment. Although some changes in vertebral artery haemodynamics were observed, blood flow to the posterior regions of the brain was not significantly altered following adjustment.

Although direct evidence specifically examining neck adjustment remains limited, available haemodynamic studies have not demonstrated a clinically meaningful reduction in cerebral blood flow following neck adjustment

4. How Common Are Serious Vascular Events?

Serious vascular events following neck adjustment appear to be rare, but we do not know the exact treatment-related risk.

Gorrell et al. (2023) reported no serious adverse events among 7,518 participants receiving spinal manipulation in the included randomised clinical trials.

Pankrath et al. (2024) similarly found no significant difference in adverse-event rates between cervical HVLA manipulation and various control interventions, including sham manipulation, mobilisation and exercise. All adverse events reported in the included trials were classified as mild.

Rare does not mean impossible, but the exact risk remains uncertain. Because these events are rare, even large clinical trials may not be able to reliably detect or quantify them.

5. Can We Identify Vascular Risk Before a Neck Adjustment?

There is no single test that can tell us with certainty that the arteries in the neck are “clear”.

Hutting et al. (2013) systematically reviewed premanipulative vertebrobasilar insufficiency tests and found limited evidence for their diagnostic accuracy, with low sensitivity (0–57%). This means that a negative positional test cannot reliably rule out vascular pathology.

The contemporary International IFOMPT Cervical Framework (Rushton et al. , 2023) instead emphasises looking at the whole clinical picture — including history, symptoms, risk factors and examination findings.

Several factors have been associated with cervical artery dissection, including migraine, hypertension, recent infection, minor trauma and certain genetic, familial and connective-tissue factors (Jacobs et al. , 2026). However, cervical artery dissection can sometimes resemble musculoskeletal neck pain, and its presentation can vary considerably, with insufficient evidence to determine the diagnostic accuracy of individual red flags (Feller et al. , 2026).

No single risk factor or clinical feature should therefore be considered diagnostic on its own.

[Reference]

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Moser, N., Mior, S., Noseworthy, M., Côté, P., Wells, G., Behr, M. and Triano, J. (2019) ‘Effect of cervical manipulation on vertebral artery and cerebral haemodynamics in patients with chronic neck pain: a crossover randomised controlled trial’, BMJ Open, 9, e025219. doi:10.1136/bmjopen-2018-025219.

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Whedon, J.M., Anderson, B., Mackenzie, T.A., Grout, L., Moonaz, S., Lurie, J.D. and Haldeman, S. (2025) ‘Observational study of the safety of chiropractic vs medical care among older adults with neck pain’, Journal of Manipulative and Physiological Therapeutics, 48(1–5), pp. 37–46. doi:10.1016/j.jmpt.2025.07.002.